Referral to emergency

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.

  • if pancytopenia is present or any bicytopenia with large lymph nodes, hepatomegaly and/ or splenomegaly
  • ongoing bleeding
  • severe anaemia with signs of cardiac failure and/ or other organ dysfunction
  • fever >38.5 with neutropenia
  • first presentation acute immune thrombocytopenic purpura (ITP) - refer to emergency via general paediatrics

Please contact the on-call registrar to discuss your concerns prior to referral.

For clinical advice, please telephone the relevant specialty service.

Women's and Children's Health Network

Inclusions

  • severe anaemia including thalassemia, red membrane disorders, red cell enzyme disorders, autoimmune disorders)
  • sickle cell disease
  • thrombocytopenia platelets <20 x 109/L
  • unexplained haemolytic anaemia
  • persistent (>6 months) moderate anaemia (Hb 60-100g/L) of any cause including thalassaemia, red cell membrane disorder, red cell enzyme disorders, and autoimmune haemolytic anaemia
  • uncertain diagnosis, abnormal white cell count, atypical blood film
  • persistent (> 6 months duration) mild cytopenia with no clinical symptoms, signs, or complications

Exclusions

Triage categories

Category 1 (appointment clinically indicated within 30 days)

  • severe anaemia (haemoglobin Hb <60g/L) including
    • thalassaemia
    • red cell membrane disorders, for example, hereditary spherocytosis
    • red cell enzyme disorders, for example, pyruvate kinase deficiency
    • autoimmune haemolytic anaemia
  • sickle cell disease
  • thrombocytopenia platelets <20 x 109/L

Patients will likely be seen in significantly less than 30 days

Category 2 (appointment clinically indicated within 90 days)

  • unexplained haemolytic anaemia
  • any of the following:
    • uncertain diagnosis
    • abnormal white cell count
    • atypical blood film
    • persistent moderate anaemia (Hb 60-100g/L) of any cause including thalassaemia, red cell membrane disorder, red cell enzyme disorders, and autoimmune haemolytic anaemia
    • any other cytopenia that fails to improve in 6 months

Regularly monitor complete blood examination, should the cytopenia progress to category 1 referral parameters.

Category 3 (appointment clinically indicated within 365 days)

  • persistent (> 6 months duration) mild cytopenia with no clinical symptoms, signs, or complications

Essential referral information

Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

  • family history
  • important developmental or psychosocial issues or other barriers to accessing care
  • relevant medical history
  • medications
  • allergies

Pathology results

  • all referrals
    • complete blood examination (CBE)
    • electrolytes, urea, creatinine (EUC)
    • liver function tests (LFTs)
    • lactate dehydrogenase (LDH)
    • uric acid (for neutropenia)
    • serology (for clinical suspicion):
      • Epstein-Barr Virus (EBV)
      • cytomegalovirus (CMV)
  • anaemia referrals:
    • ferritin
    • reticulocyte count
    • direct antiglobulin test (DAT)
    • haemoglobin variant analysis (if microcytic)

Additional information to assist triage categorisation

  • immunoglobulin G (IgG), immunoglobulin A (IgA), immunoglobulin G (IgG) for neutropenia and thrombocytopenia
  • antinuclear antibodies (ANA)
  • C-reactive protein (CRP)
  • B12 and folate if macrocytic

Clinical management advice

Regularly monitor complete blood examination, should the cytopenia progress to category 1 referral parameters.

Neutropenia

Neutropenia is defined as the absolute neutrophil count (ANC) of <1.5 x 109/L, except for neonates within the first week of life and infants where the lower limit of normal is 5.0 x 109/L and 1.0 x 109/L, respectively.

Neutropenia is categorised as:

  • mild – ANC 1.0-1.5 x 109/L
  • moderate – ANC 0.5-1.0 x 109/L
  • marked – ANC <0.5 x 109/L

Benign ethnic neutropenia (BEN) is an inherited neutropenia mainly occurring among people of African or Middle Eastern descent. The neutrophil count in this condition is usually between 1-1.5 x 109/L however it can occasionally be less than 1.0 x 109/L. and is not usually associated with an increased risk of infections.

Thrombocytopenia

Thrombocytopenia is defined as platelet count <150 x 109/L. Most patients with platelet count of >50 x 109/L are asymptomatic.

Thrombocytopenia is categorised as:

  • mild: platelet count 100-140 x 109/uL
  • moderate: 50-100 x 109/uL
  • marked: <50 x 109/uL

Clinical resources

Consumer resources

Reason for request

  • to establish a diagnosis
  • for treatment or intervention
  • for advice and management
  • for specialist to take over management
  • for a specified test/investigation the General Practitioner cannot order
  • for other reason (e.g. rapidly accelerating disease progression)
  • transfer of care from another tertiary service
  • clinical judgement indicates a referral for specialist review is necessary.

Patient demographic details

  • full name, including aliases
  • date of birth
  • residential and postal address
  • telephone contact number/s – home, mobile and alternative
  • Medicare number, where eligible
  • name of the parent or caregiver, if appropriate
  • preferred language and interpreter requirements
  • identifies as Aboriginal and/or Torres Strait Islander

Clinical modifiers

  • impact on employment
  • impact on education
  • impact on home
  • impact on activities of daily living
  • impact on ability to care for others
  • impact on personal frailty or safety
  • identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery, where surgery is a likely intervention.
  • Choice to be treated as a public or private patient.
  • Compensable status, e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.
  • Relevant social history, including identifying if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf.
  • Triage of a specialist outpatient referral is based on clinical decision making to allocate an appropriate urgency categorisation.
  • Where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
  • A change in patient circumstance (such as condition deteriorating or pregnancy) may affect the urgency categorisation and should be communicated as soon as possible.
  • All new referrals will be triaged by a consultant and appointment times scheduled according to clinical urgency.

Adolescents transitioning from paediatric to adult specialist services require a formal handover from paediatric specialist clinician to adult specialist clinician as well as a formal referral from the referring specialist to ensure initial transfer of care is completed.

The General Practitioners role in this process is to provide support to patients as part of holistic care. All ongoing referrals to specialists can subsequently be provided by the General Practitioner once the transfer of care has occurred.