An adult in a skilled‑nursing facility with marked leukocytosis and elevated hemoglobin suggestive of polycythemia vera—does he need hospital admission for evaluation and treatment?

Hospital Transfer Decision for SNF Patient with Leukocytosis and Suspected Polycythemia Vera

This patient does not require immediate hospital transfer from the skilled nursing facility if they are asymptomatic, hemodynamically stable, and have no evidence of acute thrombosis or bleeding complications. 1, 2

Immediate Assessment Required at SNF

Before making the transfer decision, the following must be evaluated:

• Bleeding symptoms: Check for petechiae, purpura, mucosal bleeding, or signs of intracranial hemorrhage 1
• Thrombotic symptoms: Assess for chest pain, dyspnea, unilateral leg swelling, neurological deficits, or abdominal pain (splanchnic thrombosis) 2, 3
• Microcirculatory symptoms: Document presence of erythromelalgia, visual changes, headache, or pruritus 3
• Vital signs stability: Confirm normal blood pressure, heart rate, and oxygen saturation 4
• Mental status: Rule out acute confusion or altered consciousness 4

Criteria Mandating Hospital Transfer

Transfer to hospital is required if ANY of the following are present:

• Active thrombosis or bleeding (arterial or venous events, including unusual sites like splanchnic veins) 2, 3
• Extreme thrombocytosis (platelet count ≥1000 × 10⁹/L) with bleeding risk from acquired von Willebrand disease 3
• Symptomatic hyperviscosity (severe headache, visual disturbances, altered mental status, transient ischemic symptoms) 3, 5
• Hemodynamic instability or signs of cardiovascular compromise 4
• Acute leukemic transformation (presence of blasts on peripheral smear, rapid clinical deterioration) 2, 6
• Severe symptoms requiring urgent cytoreduction (marked splenomegaly with abdominal pain, severe pruritus unresponsive to antihistamines) 3

Outpatient Management Pathway (If Stable)

If the patient is asymptomatic or has only minor symptoms, outpatient hematology referral within 24-72 hours is appropriate: 1, 7, 8

Immediate Actions at SNF:

• Confirm diagnosis: Obtain JAK2 V617F mutation testing (present in >95% of PV cases) 3, 6
• Assess thrombosis risk: Document age (≥60 years = high risk) and prior thrombosis history 2, 3
• Initiate aspirin: Start low-dose aspirin 81 mg daily if no contraindications (active bleeding, severe thrombocytopenia) 2, 3, 6
• Arrange urgent hematology follow-up: Within 24-72 hours for treatment planning 1, 7, 8

Phlebotomy Considerations:

• Goal hematocrit <45% to reduce thrombotic risk 2, 3, 6
• Can be performed at SNF or outpatient setting if patient is stable 3
• Hospital admission is not required solely for phlebotomy in stable patients 2

Risk Stratification for Thrombosis

High-risk features requiring more aggressive monitoring (but not necessarily immediate hospitalization):

• Age >60 years 2, 3
• Prior thrombosis history 2, 3
• Leukocytosis (increases thrombotic risk, particularly in arterial events) 9
• JAK2 mutation burden 2
• Cardiovascular risk factors (smoking, hypertension, diabetes) 6

Common Pitfalls to Avoid

• Do not delay hematology referral beyond 72 hours for newly diagnosed myeloproliferative neoplasms 1, 7, 8
• Do not withhold aspirin in stable patients without contraindications, as it significantly reduces thrombotic events 2, 3, 6
• Do not assume normal hematocrit excludes PV if plasma volume is expanded (particularly in young women with isolated thrombocytosis) 5
• Do not overlook unusual thrombosis sites (splanchnic, cerebral venous sinus) which occur in 7% of PV patients 3
• Do not initiate cytoreductive therapy (hydroxyurea, interferon) without hematology consultation, as this decision requires risk stratification 2, 3

Documentation and Communication

Ensure the following before deciding on outpatient management:

• SNF staff educated on warning signs requiring emergency transfer (acute bleeding, neurological changes, chest pain, severe dyspnea) 1
• Clear protocol for urgent hematology contact within 24-72 hours 1, 7, 8
• Confirmation that patient can adhere to aspirin therapy and phlebotomy schedule 4
• Written instructions for monitoring symptoms and when to seek emergency care 1, 8

The decision hinges on symptom presence and stability rather than laboratory values alone. 1, 2 Asymptomatic patients with marked leukocytosis and elevated hemoglobin can safely remain at the SNF with expedited outpatient hematology follow-up, provided there are no acute thrombotic or bleeding complications and the facility can provide appropriate monitoring. 1, 7, 2