Calls from the Public

Poison control centers provide information to the public regarding poisoning exposures and respond to requests for information about poisons—defined as calls in which there is no actual exposure discussed (Hoffman, 2002). Calls to poison control centers can be made directly by the public using a toll-free telephone number or through referrals to centers via 911 or other emergency numbers. Human exposures or suspected exposures represent 68 percent of all calls, and requests for information represent 32 percent (Watson et al., 2003). In 2002, there were 2.38 million human exposure calls and 1.1 million information calls to poison control centers across the country (see Table 5-2 for the content of these calls). Approximately 85 percent of the human exposure calls were categorized as unintentional, 11.7 percent as intentional, and 2.4 percent as adverse reaction. Furthermore, most calls were judged to have little or minor effect, with 74 percent managed in the home (Watson et al., 2003).

TABLE 5-2

Exposure Call Content (most common agents involved in 2,380,028 exposure calls reported to the TESS data collection system in 2002).

Assistance to the public regarding human exposures includes assessment of the type and severity of poisoning, suggestions for at-home care when appropriate, reassurance to the caller, and referral to a health care provider when necessary. Follow-up is provided with callbacks as needed to assure satisfactory resolution of the episode. Preventive measures are suggested to avoid similar poisoning episodes, such as removing certain items from the home or placing them out of reach of children. When callers are referred to a health care facility, that facility is notified and information regarding the case and the relevant toxicology of the poison involved is made available. Access to the public is provided via around-the-clock toll-free telephone lines staffed by poison control center personnel. Most calls are answered by specialists in poison information (SPIs) or poison information providers (PIPs) (Zuvekas et al., 1997). Medical toxicologists are available at all times by telephone for backup consultation. Poison control centers also have consultants on call with specific areas of expertise, such as mycologists and herpetologists. Tables 5-2 and 5-3 present the most common reasons for exposure and information calls, respectively.

TABLE 5-3

Information Call Content to Poison Control Centers (most common topics involved in 1,110,635 information calls reported to the TESS data collection system in 2002).

Poison control centers also respond to calls from the public regarding animal exposures to poisons; exposures to chemicals at work or in the home; requests to evaluate symptoms that the caller believes may be related to poisoning; questions about environmental pollutants, plants, herbal medicines, drug interactions, or envenomations; or requests for general information about poisoning topics (e.g., first aid) (Leikin and Krenzelok, 2001). The range of topics is broad in part because people call the poison control center when they are not sure who else to call. Such calls may be referred to more appropriate agencies, for example, the local public health department for possible food poisoning. Nearly all of the poison control centers maintain websites with information on selected topics and links to other information sources, and callers may be referred to those websites when appropriate.

Calls from Health Care Professionals

Poison control centers provide information to a wide variety of health care providers regarding exposures and potential exposures. As the focus of poison control centers has shifted from pediatric exposures to include adult exposures, which are far more likely to result in significant morbidity and mortality, consultation with health care providers has become an increasingly important function. Users of this service include emergency medical technicians (EMTs) who obtain prehospital treatment guidance; first responders such as firefighters or HAZMAT teams; nurses and physicians in hospitals and clinics; nurses and social workers who staff advice lines; and physicians, nurses, or other professionals with public health agencies (Hoffman, 2001; Leikin and Krenzelok, 2001). Consultation with emergency department and intensive care unit staff has become an important role for poison control center staff. Emergency or critical care physicians or nurses managing poisonings in their clinic are given guidance related to poison identification, anticipated toxic effects, initial intervention, and whether transfer to an emergency department or inpatient facility is needed. Emergency physicians and nurses may receive suggestions regarding differential diagnosis, initial intervention, selection of laboratory tests, where to send nonstandard laboratory test requests, the need for consultation and the identification of appropriate consultants, and disposition of the patient.

Poison control center staff provide guidance regarding the indications for specific procedures such as hemodialysis, the availability and use of specific antidotes, or the need for transfer when the necessary facilities or expertise needed for patient management are not available. Staff assist with arranging patient transfers or putting physicians in contact with appropriate consultants. Specific reference materials or pertinent literature are provided. Calls from health care professionals are handled initially by SPIs or PIPs, but are often referred to medical toxicologists. Approximately 20 percent of the human exposure calls made to poison control centers come from health care facilities (Poison Control Center Annual Reports, 2000–2002).

Follow-up calls from the poison control center are used to ascertain patient status, symptom resolution, compliance with recommended therapy, and where appropriate, status after discharge. For both public and health care professional callers, health care agencies are contacted when they can assist with patient care or when reporting is required or appropriate. The adverse effect of Health Insurance Portability and Accountability Act regulations, or hospitals' interpretations of these guidelines, on the ability to obtain follow-up information is an issue that poison control centers are currently addressing (http://fpicn.org/HIPAA_Compliant.htm).

Technology Support for Telephone Consultation

Since 2001, the American Association of Poison Control Centers (AAPCC) has been responsible for establishing and implementing a national toll-free telephone number (1-800-222-1212) that is advertised by all U.S. poison control centers. Individuals (either from the public or health care professionals) who wish to report a poisoning exposure or ask for information regarding a product or procedure can call this number and be routed to the local poison control center for a response. Centers may continue to maintain their own local and toll-free numbers because people in their service area are familiar with these numbers and have them posted at home. California maintains a separate toll-free number for use by health care professionals. Specialized telecommunication devices for communication with deaf individuals are used, and there are links to agencies that specialize in communicating with them. Translation services are available to ensure rapid and accurate communication with individuals who do not speak English or who speak English as a second language. Generally, these services are provided through a three-way conference call with a translation service equipped to translate several languages; however, four centers have bilingual speakers onsite 24 hours a day, 7 days a week (http://www.aapcc.org/pccsurveyresults/2002/2002Table4.pdf).

The primary information aid in exposure analysis and treatment is Poisindex^® published by Micromedex. As noted in Chapter 4, Poisindex provides (1) information on the composition of most commercial and natural products; (2) a description of the toxicity of the products; and (3) suggested treatment options. Micromedex employs an internal staff to obtain and code products as well as to prepare the management documents for review by an outside editorial board. The embedded product codes are used by AAPCC to connect each poison control center case to a product or category.

As the call progresses, the certified specialist in poison information (CSPI) or SPI collects and records demographic information about the caller (e.g., age, gender, geographic location), notes the product code associated with the exposure, judges severity, and provides treatment recommendations using one of four commercially available data collection systems (discussed in Chapter 8) that automatically upload data every 4 to 10 minutes to the Toxic Exposure Surveillance System (TESS) housed at AAPCC headquarters in Washington, D.C. Electronic matching between the computerized case reports filled out by the specialists and the product and ingredient indexes of Poisindex^® is automatic and works seamlessly with all four electronic data collection programs.

HAZMAT, Occupational, or Environmental Exposures

Poison control centers are an integral part of most local HAZMAT (hazardous materials) response protocols, such as a chemical leak from an overturned tanker truck (Burgess et al., 1997; Mrvos et al., 1988). In this capacity, poison control centers work in close collaboration with local public health agencies and other agencies with responsibilities in this area, such as fire and police departments. Centers may be accessed in these situations by the public, responders at the incident scene, health care providers caring for exposed individuals, or public health agencies. The role of the poison control center includes providing information to individuals with exposures or potential exposures, assisting in triaging injured patients and notifying the receiving health care facility, providing information regarding the toxicology of the chemicals involved in the incident and the management of exposed patients, and gathering data regarding exposures (e.g., locations, types of injuries) that may be useful for managing the incident or for surveillance and follow-up. Poison control centers serve a similar role in acute or chronic occupational exposures, providing initial information regarding the toxicology of the exposure, assistance with initial triage and management, and coordination with responsible public health agencies (Blanc and Olson, 1986). Centers also have been accessed following natural disasters such as earthquakes to provide information on air and water quality (Nathan et al., 1992).

All-Hazards and Other Public Health Emergencies

Poison control centers can play an important role in preparedness and response to acts of bioterrorism, chemical terrorism, or other public health emergencies. The efforts involved in the rapidly evolving, present-day building of capacity in the areas of bioterrorism and chemical terrorism preparedness and response is likely to strengthen the ability of centers to respond to natural disasters and other threats to public health. In 2001, 3,395 exposure calls regarding agents classified in TESS as “weapons of mass destruction” (WMD) were received and acted on by poison control centers. Examples include reports of anthrax, suspicious powder, chemical weapons, and other suspicious substances.

State plans for public health and hospital emergency preparedness are beginning to acknowledge roles for poison control centers. These state programs, funded by cooperative agreement grants from the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA), help the public health system and hospitals prepare for acts of bioterrorism, outbreaks of infectious disease, and other public health threats and emergencies. For a further discussion of state involvement, see Chapter 9.

To help describe the relevant services that poison control centers can provide, the following framework is adapted from the Haddon Matrix: Preevent, including planning, education, and surveillance; Event and Response, including detection, investigation, dissemination of information to the public, antidote distribution, and communication with agencies; and Recovery, including serving as an information resource for the public and health care providers.

Preevent activities include the following:

• Preparedness planning: Poison control center personnel, particularly toxicologists and pharmacists, serve in multiple capacities related to local, regional, and national emergency preparedness planning; examples include service on state and local preparedness committees and advisory groups. CDC and HRSA guidance in 2003 to state and local applicants for cooperative agreement funding for public health preparedness and response to bioterrorism specifies that poison control centers be represented on advisory committees for these cooperative agreements. Centers also assist with Strategic National Stockpile planning; help with local and regional capacity assessments related to bioterrorism preparedness; and develop diagnostic and treatment protocols and associated standardized staff education programs. Poison control centers also maintain antidote supplies and/or facilitate local/regional inventory tracking for essential medicines and other supplies.
• Surveillance: Poison control centers participate in toxicosurveillance for the identification of sentinel events that may represent intentional bioterrorist events or natural toxin exposures. Every 4 to 10 minutes, poison control centers upload case data to TESS. To assist in improving public health surveillance, CDC's National Center for Environmental Public Health, the Agency for Toxic Substances and Disease Registry (ATSDR), and AAPCC are working to convert TESS into a real-time public health surveillance system. This conversion will generate more immediate and appropriate responses to public health threats that may be related to toxins or chemicals in the environment. In addition to a national toxicosurveillance effort performed in conjunction with AAPCC, poison control centers participate in local syndromic surveillance and report notifiable conditions affecting multiple individuals to local and/or state health officials.
• Continuing education and research and preparation for bioterrorism through effective training programs: Poison control centers provide training to various groups (e.g., the public, emergency medicine residents, medical toxicology fellows, emergency physicians and nurses, and public health officials) on the medical effects of WMD. Centers also serve as a repository for specialized databases regarding agents of bioterrorism and chemical terrorism.

Event and Response activities include the following:

• Poison control centers can provide assistance with early recognition and notification of bioterrorism and chemical terrorism events; coordinate antidote distribution and guide appropriate antidote use; assist health care professionals with management of exposed patients and rescue personnel; disseminate threat and preventive/therapeutic information to the public; and provide consultative support to public health and law enforcement authorities.

Recovery activities include the following:

• Poison control centers provide a single source (i.e., one telephone number) for coordinating exposure and treatment information; serve as an information resource to the public, media, and medical practitioners regarding existing health effects in the aftermath of a terrorist act; reassure these same groups to help minimize panic; and provide information to public health agencies about the long-term effects associated with a terrorist attack and how to respond to and treat those effects.

Case vignettes illustrative of how poison control centers contribute to the investigation and management of bioterrorism events are presented in Appendix 5-A. The case study of the Rocky Mountain Poison and Drug Center illustrates the integral involvement of a center into a public health system. The Texas Poison Control Center's experience illustrates the role a poison control center can play in communicating with the public and provider community when an urgent health issue emerges, in this instance the receipt of hundreds of calls during the 2001 anthrax attacks. The Northern New England Poison Center vignette describes how a center works in the early identification of (i.e., toxicosurveillance) and response to a communitywide cluster of illness (i.e., arsenic exposure).

Nonpoisoning Exposure Information Requests to Poison Control Centers

Because of their well-publicized availability, poison control centers are often the default choice for the public to call regarding exposures to agents other than chemicals. For example, centers have received calls about Severe Acute Respiratory Syndrome and must be able to respond with appropriate information or referrals. In addition, incidents can occur in which the nature of the offending agent is unknown and could be an infectious agent or a chemical. In this case, the public, health care professionals, and public health agencies may all access the poison control center for information (Geller and Lopez, 1999).

Systematic Reporting of Exposures to a Collective Poison Control Center Database

Poison control centers currently report all exposure data to the TESS database (Watson et al., 2003). These data are used to document the spectrum of exposures causing poisonings and their consequences. While this database represents only the fraction of all exposures that generate calls to centers (Blanc et al., 1995), the data may be used to identify trends and potential targets for education, surveillance, public health measures, or research. This type of database represents a unique opportunity to collect detailed data regarding certain types of poisoning exposures.

Sentinel Event Reporting

Sentinel events are initial cases or events indicating a more widespread problem. Poison control centers, because of their telephone consultation function, may be the first part of the health care system to become aware of new types of poisonings in the community, such as previously unknown adverse reactions to a medication, the use of a new type of drug of abuse (e.g., scopolamine poisoning among heroin users [Morbidity and Mortality Weekly Report, 1996]), or an unusual illness suggestive of bioterrorism. Centers may also recognize clusters of cases that would otherwise go unnoticed as isolated events. Prompt reporting of these events to the appropriate public health agencies and in the medical literature can help provide an early warning and offer the option of generating a timely response. Poison control centers also notify public health agencies of reportable diseases or cases or incidents that may be of interest, such as suspected food poisoning.

Primary Prevention: Public Education

Poison control centers provide public education on poisoning prevention (Zuvekas et al., 1997). This education may be offered in collaboration with public health agencies, nongovernment organizations, or industry. The role of the centers is to provide expertise in poisonings; the collaborator provides expertise in injury prevention, as well as offering the infrastructure for public education (see discussion in Chapter 8).

Secondary Prevention: Utilization of Health Care Resources

A potential benefit of having poison control centers available to answer poisoning calls is the appropriate triage of patients to health care facilities when needed (improving patient care), and avoiding the use of health care facilities when not needed (reducing costs). Poison control centers provide public education focused on facilitating these outcomes, such as calling the center for poisoning questions or exposures rather than calling physicians' offices.

Medical Toxicologists

Medical toxicology is a subspecialty for physicians defined by the Accreditation Council for Graduate Medical Education (ACGME) as a “clinical specialty that includes the monitoring, prevention, evaluation and treatment of injury and illness due to occupational and environmental exposures, pharmaceutical agents, as well as unintentional and intentional poisoning in all age groups” (Accreditation Council for Graduate Medical Education, 2003). Medical toxicologists first complete training in any primary medical specialty (usually emergency medicine, occupational medicine, pediatrics, internal medicine, or pathology), and then an additional 2-year fellowship in medical toxicology (Wax and Donovan, 2000).

AAPCC requires a board-certified medical toxicologist as medical director as a condition of poison control center certification. In this capacity, medical toxicologists provide overall clinical supervision and medical backup of poison control center personnel and contribute to teaching, administrative, and research efforts within the center. Medical toxicologists also serve as consultants to centers, providing medical backup, teaching, or research expertise.

Common roles for medical toxicologists outside poison control centers include direct care or consultation regarding poisoned patients, teaching of medical toxicology fellows and other health care professionals, toxicology research, and medicolegal consultation. A smaller number of medical toxicologists work in various capacities in public health or government agencies, including CDC and the U.S. Food and Drug Administration, or in industry (Wax and Donovan, 2000).

Managing Direction

According to the AAPCC criteria for certification, the managing director of a certified poison control center provides “direct supervision of poison center staff, strategic planning, and oversight of administrative functions of programs (e.g., staff training, quality assurance, budgeting, etc.)” (American Association of Poison Control Centers, 1998, p. 6). A managing director with responsibilities for toxicological supervision must be board certified or board prepared in applied toxicology. This position can be filled by a physician, a pharmacist, or a nurse. In some centers the managing director is also the medical director.

Specialists in Poison Information

Specialists in poison information are the primary poison control center staff who answer telephones and respond to callers wanting information regarding poisonings. A 1998 survey of centers in the United States reported that SPIs were nurses (53 percent), pharmacists (40 percent), or physicians (3.5 percent) or had other backgrounds (2 percent) (Youniss et al., 2000). A certification process for SPIs is offered by AAPCC, allowing them to become certified specialists in poison information (these procedures are discussed in the section on quality assurance).

In addition to their primary role in answering poison control center telephone calls from the public and professionals, SPIs may supervise PIPs (staff with less advanced training in health care), serve administrative functions, conduct public or professional education, or participate in research projects. However, most SPI time is spent responding to telephone calls (75 percent) or handling administrative tasks (20 percent), with little time devoted to education (3 percent) or research (1 percent) (Zuvekas et al., 1997).

Poison Information Providers

Like SPIs, the primary role of PIPs is answering poison control center telephone calls from the public and health care professionals. PIPs differ from SPIs in that they lack training as nurses, pharmacists, or physicians, but rather have a variety of other health-related backgrounds. Because they have less advanced training in health care, PIPs working in AAPCC-certified poison control centers are required to do so under the onsite supervision of a CSPI or the managing or medical director of the center. The addition of PIPs to the more traditional use of SPIs to answer center telephones serves to enlarge the pool of providers available for such employment and to reduce costs.

Health Educators

Most poison control centers have a full- or part-time health educator whose primary role is education of the public regarding poisoning prevention and promotion of poison control center use. These efforts are often focused on the pediatric age group. In some centers, SPIs contribute to public education (Zuvekas et al., 1997). The role of health educators is discussed in more detail in Chapter 8.

Consultants

A wide variety of consultants provide additional capacity and expertise to poison control centers. Centers have medical toxicologists who serve as consultants to provide additional medical backup to SPIs and PIPs, to share on-call responsibilities with the medical director, or to contribute to teaching or research. In addition, poison control centers have consultants with expertise in specialized areas, such as veterinary medicine, herpetology, or mycology. These individuals are important to centers because it is not possible for their staff to have the detailed knowledge needed to manage the wide variety of poisonings encountered. Consultants typically volunteer their services and represent backgrounds as diverse as their subject matter.

SPIs and PIPs

The training of both SPIs and PIPs is accomplished by the poison control center via lectures, assigned readings, observing center staff, participating in hospital rounds, and responding to poison information or exposure telephone calls under supervision. There is no standard curriculum or published description for such training. AAPCC requires of certified poison control centers only that such training be under the supervision of the center medical director. SPI training takes from 3 months to a year to allow the SPI to answer center telephones independently (Committee briefings from Dart, 2003; Heard, 2003; and Trestrail, 2003).

Medical Toxicologists

Poison control centers provide an essential part of the training of medical toxicology fellows. ACGME specifically requires that accredited fellowship programs have an affiliation and geographic proximity to a poison control center for the clinical portion of their training. This center-based training includes answering telephones, providing medical backup to SPIs and PIPs, providing direct consultation to health care professionals calling the center, interacting with health care agencies that collaborate with or use the center, understanding center data collection and reporting, and gaining experience in center administration. A survey of medical toxicologists indicated that 46 percent of their clinical experience during training involved center-based activities (Wax and Donovan, 2000).

Currently, 12 poison control centers (ACGME-accredited programs) offer medical toxicology fellowships. In some cases, medical toxicology fellows spend time at a second center that serves a different geographic area or patient population or has staff with different expertise in order to gain a broader range of experience.

Clinical Toxicology Fellowships

Several poison control centers offer 1- or 2-year clinical toxicology fellowship training programs for clinical pharmacists (e.g., see http://www.pharmacy.umaryland.edu/pps/residents/toxicology.htm and http://www.hscj.ufl.edu/pharmacy/residency/index.html). There are no uniform criteria, curricula, or accreditation processes for such fellowships. The purpose of these fellowships is to prepare clinical pharmacists for careers focusing on the management of the poisoned patient, but their content may vary depending on the institution and the interests of the trainee.

Professional Continuing Education

Poison control centers provide professional continuing education in their service area. The type and extent varies greatly, reflecting the needs of the community, the availability and funding of center staff, and the particular expertise of the staff (Zuvekas et al., 1997). Courses or individual lectures may be located at or near the poison control center, or in communities throughout the service area. The target audience may include physicians, nurses, pharmacists, emergency medical technicians, veterinarians, dentists, public health workers, or government employees who share responsibility for some aspect of poisoning prevention or management, such as HAZMAT responders. Poison control center staff often share the podium with other professionals at such conferences because the range and scope of toxicology is broad and collaboration with other professionals and agencies is an integral part of both center service and educational efforts.

Poison control center staff also contribute to professional continuing education via publications, including editing toxicology textbooks, writing book chapters or review articles, contributing sections to references such as Poisindex^®, and preparing review or teaching documents for government agencies such as ATSDR.

Education of Other Health Care Professionals

Poison control centers contribute to the education of a wide variety of health care professionals, including medical, nursing, pharmacy, and dental students; medical and pharmacy residents and fellows; and EMTs. Training may include rotations through the centers where they observe or assist with call management or information retrieval, lectures in formal courses, or the participation of poison control center personnel in hospital rounds. Education of these trainees is important as a means of disseminating standards of care for the poisoned patient, and in creating interest in this field among younger trainees who might later choose to obtain further training in toxicology or careers involving poison control centers.

Poison control center education of trainees also contributes to the scope of their education. However, there are many more training programs for health care professionals than there are poison control centers, and not all training programs are located near a center. Thus the extent to which poison control centers contribute to the education of health care professionals varies greatly (Zuvekas et al., 1997). For example, a survey of emergency medical technician training programs showed that 81 percent of such programs had access to a regional poison control center, and 11 percent offered rotations in centers to trainees (Davis et al., 1999). Where such relationships are established, poison control centers can contribute to the education of health care professional students, residents, or fellows through lectures incorporated into their required courses (e.g., a lecture on management of overdose as part of a pharmacology course for medical students), as clinical rotations in which students spend time in the center, or as participants in center research projects. This form of poison control center educational involvement is not mandated for any health care professional training (other than that of medical toxicologists).