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.

  • neutrophil count < 0.5 x 109/L but otherwise well, please call duty haematologist
  • active sepsis in association with unexplained neutropenia. Contact the duty haematologist via switchboard so the referral may be expedited, and the patient reviewed as soon as possible.

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

For clinical advice, please telephone the relevant specialty service.

Central Adelaide Local Health Network

Northern Adelaide Local Health Network

Southern Adelaide Local Health Network

Inclusions

  • ongoing persistent neutropen

Exclusions

  • isolated neutropenia <3 months duration (resolved neutropenia)

Triage categories

Category 1 (appointment clinically indicated within 30 days)

  • neutropenia (absolute neutrophil count ANC <0.5 x 109/L) with no sepsis in association with anaemia or thrombocytopenia, lymphadenopathy, or splenomegaly

Category 2 (appointment clinically indicated within 90 days)

  • ongoing persistent neutropenia without evidence of anaemia or thrombocytopenia with ANC 0.5 to 1.0 x 109/L

Category 3 (appointment clinically indicated within 365 days)

  • ongoing persistent neutropenia of 1.0 to 1.5 x 109/L

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.

  • ethnic origin
  • current medication list
  • history of autoimmune conditions
  • blood results:
    • complete blood examination (CBE)
    • blood film examination
    • liver function tests (LFTs)
    • electrolytes, urea, creatinine (EUC)
    • estimated glomerular filtration rate (eGFR)
    • lactate dehydrogenase (LDH)
    • lymphocyte surface markers on peripheral blood
    • antinuclear antibody (ANA), extractable nuclear antigen antibodies (ENA), anti-double stranded DNA (dsDNA)
  • history of previous CBE results
  • viral screen including human immunodeficiency virus (HIV), hepatitis B and C serology

Clinical management advice

Neutropenia is defined as an absolute neutrophil count (ANC) < 1.8 x 109/L. Causes of neutropenia include drugs, viral infections, autoimmune conditions, benign ethnic neutropenia, cyclical neutropenia, B12 or folate deficiency, bone marrow disorders such as myelodysplasia, aplastic anaemia, or malignant infiltration of the marrow by a non-haematological malignancy.

Neutropenia is categorised as:

  • mild – ANC 1.0-1.7 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.

Suggested assessment in primary care of a patient who is asymptomatic and has a mild neutropenia (ANC >1.0 x 109/L) with or without an accompanying mild thrombocytopenia but normal haemoglobin.

  • the blood test should be repeated 6-8 weeks later with a blood film review.
  • review of medications that may contribute to lowering of neutrophil count for example, anti-psychotic drugs such as olanzapine or a high doses of omeprazole.

Clinical 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.