When should a patient be referred to hematology?

When to Refer to Hematology

Patients with newly diagnosed immune thrombocytopenia (ITP) and platelet counts <20 × 10^9/L should be referred to a hematologist within 24-72 hours of diagnosis, regardless of whether they are managed as inpatients or outpatients. 1, 2

Urgent Referral Indications

• Newly diagnosed ITP with platelet count <20 × 10^9/L requires expedited follow-up with a hematologist within 24-72 hours 1, 2
• Established ITP patients with platelet count <20 × 10^9/L need prompt hematology follow-up 1, 2
• Patients with significant mucosal bleeding, regardless of platelet count 2, 3
• Patients with hematologic malignancies including:
  • Acute myeloid leukemia (AML) 1
  • Acute lymphoblastic leukemia (ALL) 1
  • Chronic myeloid leukemia (CML) resistant to or intolerant of TKIs 1
• Patients with persistent monocytosis (>1×10^9/L) with concurrent unexplained cytopenias 4
• Patients with symptoms suggestive of hematologic malignancy (fever, weight loss, bruising, fatigue) 5

Standard Referral Indications

• ITP patients who are corticosteroid-dependent or unresponsive to corticosteroids after ≥3 months 2
• Patients with persistent monocytosis (>1×10^9/L) for ≥3 months without clear reactive cause 4
• Patients with suspected myelodysplastic syndromes (MDS) or myeloproliferative neoplasms 1, 4
• Patients with multiple myeloma, particularly those with high-risk cytogenetic changes 1
• Patients with refractory or relapsed Hodgkin lymphoma or non-Hodgkin lymphoma 1
• Patients with suspected bleeding disorders that cannot be explained by initial diagnostic investigations 6, 7

Special Populations

• Elderly patients (>60 years) with thrombocytopenia may require more aggressive management due to higher bleeding risk 2, 3
• Patients on anticoagulant or antiplatelet medications with thrombocytopenia have increased bleeding risk and need specialized management 2, 3
• Children with ITP should have follow-up with a hematologist within 24-72 hours of diagnosis 2
• Patients with social concerns or limited access to care may benefit from earlier referral 1, 2

Admission vs. Outpatient Management

• Adults with newly diagnosed ITP and platelet count <20 × 10^9/L who are asymptomatic or have minor mucocutaneous bleeding should be admitted rather than managed as outpatients 1, 3
• Adults with established ITP and platelet count <20 × 10^9/L who are asymptomatic or have minor mucocutaneous bleeding can be managed as outpatients with expedited hematology follow-up 1
• Adults with platelet count ≥20 × 10^9/L who are asymptomatic or have minor mucocutaneous bleeding should be managed as outpatients 1, 3

Common Pitfalls to Avoid

• Failing to ensure timely follow-up with a hematologist within 24-72 hours for urgent conditions 1, 2
• Not providing adequate patient education about warning signs requiring emergency care for outpatients 2, 3
• Overlooking the need for specialized testing that may only be available through hematology specialists 8
• Delaying referral for patients with suspected hematologic malignancies 5
• Failing to recognize that bleeding disorders of unknown cause often require hematology expertise for proper diagnosis and management 6

Laboratory Findings Warranting Hematology Referral

• Unexplained cytopenias in any cell line 4, 5
• Abnormal peripheral blood smear showing immature myeloid cells or dysplastic features 4
• Persistent monocytosis with or without other abnormal blood counts 4
• Elevated white blood cell count without clear infectious or inflammatory cause 5
• Abnormal coagulation studies that cannot be explained by common causes 6, 7