Abnormal Blood Counts: To Refer or not to Refer? Dr Arne de Kreuk Haematology Consultant Croydon Health Services NHS Trust

Transcription

1 Abnormal Blood Counts: To Refer or not to Refer? Dr Arne de Kreuk Haematology Consultant Croydon Health Services NHS Trust 14/09/201

2 9/14/201

3 Why do GPs refer? to establish the diagnosis (52 per cent) for treatment or an operation (4 per cent) for a specified test/investigation which the GP cannot order (33 per cent) for advice on management (32 per cent) for a specialist to take over management (not known) for reassurance for the GP/second opinion (17 per cent) for reassurance for the patient and/or their family (7 per cent) for other reasons (11 per cent). 9/14/201

4 Approaches towards quality improvement in referral Referral guidelines Educational interventions Organisational interventions Financial incentives 9/14/201

5 (CQUIN) Indicator 6: offering Advice & Guidance Very large variations nationally in the number of patients being referred to hospital outpatients. Suggests that for some referrals, patients could be managed differently! Introduction of A&G services does reduce referral rates. Where GPs asked for and subsequently received specialist A&G, only 23% of patients went on to be referred to secondary care GP requests for A&G where a response was not received, 74% went on to be referred to secondary care 9/14/201

6 Some numbers CHS: 10 new haematology referrals per month 54 telephone Advice & Guidance requests per month from GPs 9 E-Advice & Guidance requests per month from GPs 9/14/201

7 Referral guidelines in Haematology: CHS: currently no published guidelines Various guidelines on the internet Financial incentives?future: E-referral system in combination with decision support tool 9/14/201

8 Tonight: Discuss two common abnormalities frequently raised in A&G requests Short cases Review draft decision tree Heading towards quality improvement in referral process 9/14/201

9 NEUTROPENIA Isolated neutrophil count below laboratory normal range (<1.5 x 10 9 /l). Mild x 10 9 /l Moderate x 10 9 /l Severe <0.5 x 10 9 /l 9/14/201

10 How would you approach the following cases with a neutrophil count of 0.? A 46-year old man who appears pale, has several petechiae and with a temperature of 39 Celsius A 63-year old woman 10 days after chemotherapy for breast cancer A 23-year old man who seems apparently well A 7-year old man who seems apparently well 9/14/201

11 9/14/201 Neutropenia: a systematic approach

12 9/14/201 Neutropenia: a systematic approach

13 9/14/201 Neutropenia: a systematic approach

14 9/14/201 Neutropenia: a systematic approach

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16 9/14/201 Neutropenia: a systematic approach

17 Neutropenia: a systematic approach Neutrophil count between 1.0 and 1.5: - Investigations in primary care. - Repeat after 6 weeks 9/14/201

18 Neutropenia: investigations in primary care Review ethnicity of all patients. A neutrophil count between x 109/l is normal in people of Afro-Caribbean and Middle Eastern ancestry. Signs of a viral infection? Check medication. Common drug causes include antipsychotics / sulphonylureas / propylthiouracil / carbimazole / sulphonamides / cotrimoxazole / bendroflumethazide / anticonvulsants / NSAIDs / and ranitidine. Examine for lymphadenopathy and splenomegaly Request Blood film, B12 / folate, ANA, HIV serology (independent of perceived risk) 9/14/201

19 9/14/201 Neutropenia: a systematic approach

20 THROMBOCYTOSIS Persistent increase in the platelet count above laboratory normal range (>450 x 10 9 /l). 9/14/201

21 How would you approach the following cases with a platelet count of 731 x 10e9/l? A 46-year old man with active ulcerative colitis A 34-year old man involved in a motorbike accident 9 years ago A 23-year old woman with heavy periods A 7-year old man who seems apparently well A 57-year old woman with an acute DVT A 4-year old man with a WBC of 53.7 x 10e9/l 9/14/201

22 9/14/201 Thrombocytosis: a systematic approach

23 9/14/201 Thrombocytosis: a systematic approach

24 9/14/201 Thrombocytosis: a systematic approach

25 9/14/201 Thrombocytosis: a systematic approach

26 9/14/201 Thrombocytosis: a systematic approach

27 Final remarks: Educational intervention on neutropenia and thrombocytosis Other topics? Referral Guidelines Does this work? Organisational Interventions Current A&G pathways Software: decision aids in e-referral 9/14/201

28 Haematology Team Consultants Dr Nnenna Osuji (Medical Director) Dr Betty Cheung Dr Stella Kotsiopoulou Dr Shalini Solanki Dr Fathi Al-Jehani Dr Arne de Kreuk (Locum) Registrars Dr Anna Cowley Dr Sushama Sankpal Nursing Jackie Green (Nurse Consultant) Alison Fernando (CNS) Judith Darville Anticoagulation Dr Carol Buttriss (Lead) Dr Jane Ritchie Transfusion Sammy Conran (Transfusion Practitioner) Secretaries/ Clerical Valarie Adamson Zoe Griffin Aziza Amasai Jeanette Smythe-Macauley 9/14/201