Pediatric Annals

Understanding Poison Control and Protecting its Future

Mark A Kostic, MD, FAAEM; S Rutherfoord Rose, PharmD, FAACT, DABAT; Vikhyat S Bebarta, MD

Abstract

"What is there that is not poison? All things are poison and nothing is without poison. Solely, the dose determines that a thing is not a poison." - Paracelsus (1493-1541)

Poisoning, intentional or not, is a practice that dates to ancient times, as evidenced by cave paintings of prehistoric hunters using spearheads with depressed tips to hold poison.1 The derivation of the term toxicology, in fact, appears to be from the Greek terms toxikos ("bow") and toxikon ("poison into which arrowheads are dipped").1"3 Through the centuries, poisoning has played an important role not only in suicides and wartime but also in the succession of political and papal office. This was most evident in the 4th Century Roman Empire through the Renaissance period. Murder by poisoning remained quite popular in Italy and France through the 17th and 18th centuries and is still used around the world today. One recent example is the presumed assassination attempt of then-Ukrainian presidential candidate Viktor Yuschenko with dioxin in 2004; Yuschenko survived the poisoning and won the election, but his face remained disfigured with the effect of chloracne.

To provide some definitions for terminology used in this article, the term "toxicologist" describes a scientist or clinician who studies the toxic effects of chemicals. Laboratory technicians, basic scientists, epidemiologists, or clinicians may use this descriptioa The term "clinical toxicologist" applies to healthcare providers, many of whom complete post-graduate training, certification, or both, who are involved in the care of poisoned patients (often a medical doctor or doctor of pharmacy). A "medical toxicologist" is a physician, usually with fellowship training and subspecialty certification in the field of medical toxicology, who treats poisoned patients.

POISON CONTROL HISTORY

The first poison control center in the United States was founded in Chicago in 1953 in response to a proliferation of toxic (by today's standards) chemicals that were marketed for home use in poorly packaged and labeled containers. Ingredient information was hard to obtain. Thousands of children had been injured or killed from poisoning. The early poison centers gathered and filed information from hundreds of manufacturers, and they soon found themselves providing clinical advice rather than just product information.

During the 1960s and 1970s, hundreds of hospitals created "poison centers" in attempts to combine marketing with community service. The number of poison centers peaked in 1978 at 661. These centers often consisted of untrained nurses or pharmacists answering phone calls in the midst of their normal duties. No standards existed for reference materials, documentation, clinical advice, follow-up calls, quality assurance, or staff training. In 1983, the American Association of Poison Control Centers (AAPCC) established criteria to certify poison centers as "Regional Poison Centers," assuring the public and healthcare providers of at least minimum standards and consistency of service.

The practice of medical toxicology is relatively new, beginning in the 1970s as a subspecialty of pediatrics, with nonABMS (American Board of Medical Specialties) recognized board certification in 1974. Currently, fellowship training and ABMS-recognized board certification are offered to graduates of emergency medicine, pediatrics, and occupational medicine residencies. The American Board of Emergency Medicine has administered the certification exam since 1994.

Currently, a majority of the 300 to 400 board-certified medical toxicologists in the US are primarily trained in emergency medicine (as are 95% of the current medical toxicology fellows). Their scope of practice is varied. Some practice primarily in poison centers, providing care to poisoned patients through bedside medical consultation, phone consults with health professionals, and medical backup to SPIs. Other toxicology practitioners have their own medical toxicology inpatient service, admitting patients to the ward and intensive care units primarily. Some specialize in…

"What is there that is not poison? All things are poison and nothing is without poison. Solely, the dose determines that a thing is not a poison." - Paracelsus (1493-1541)

Poisoning, intentional or not, is a practice that dates to ancient times, as evidenced by cave paintings of prehistoric hunters using spearheads with depressed tips to hold poison.1 The derivation of the term toxicology, in fact, appears to be from the Greek terms toxikos ("bow") and toxikon ("poison into which arrowheads are dipped").1"3 Through the centuries, poisoning has played an important role not only in suicides and wartime but also in the succession of political and papal office. This was most evident in the 4th Century Roman Empire through the Renaissance period. Murder by poisoning remained quite popular in Italy and France through the 17th and 18th centuries and is still used around the world today. One recent example is the presumed assassination attempt of then-Ukrainian presidential candidate Viktor Yuschenko with dioxin in 2004; Yuschenko survived the poisoning and won the election, but his face remained disfigured with the effect of chloracne.

To provide some definitions for terminology used in this article, the term "toxicologist" describes a scientist or clinician who studies the toxic effects of chemicals. Laboratory technicians, basic scientists, epidemiologists, or clinicians may use this descriptioa The term "clinical toxicologist" applies to healthcare providers, many of whom complete post-graduate training, certification, or both, who are involved in the care of poisoned patients (often a medical doctor or doctor of pharmacy). A "medical toxicologist" is a physician, usually with fellowship training and subspecialty certification in the field of medical toxicology, who treats poisoned patients.

POISON CONTROL HISTORY

The first poison control center in the United States was founded in Chicago in 1953 in response to a proliferation of toxic (by today's standards) chemicals that were marketed for home use in poorly packaged and labeled containers. Ingredient information was hard to obtain. Thousands of children had been injured or killed from poisoning. The early poison centers gathered and filed information from hundreds of manufacturers, and they soon found themselves providing clinical advice rather than just product information.

During the 1960s and 1970s, hundreds of hospitals created "poison centers" in attempts to combine marketing with community service. The number of poison centers peaked in 1978 at 661. These centers often consisted of untrained nurses or pharmacists answering phone calls in the midst of their normal duties. No standards existed for reference materials, documentation, clinical advice, follow-up calls, quality assurance, or staff training. In 1983, the American Association of Poison Control Centers (AAPCC) established criteria to certify poison centers as "Regional Poison Centers," assuring the public and healthcare providers of at least minimum standards and consistency of service.

The practice of medical toxicology is relatively new, beginning in the 1970s as a subspecialty of pediatrics, with nonABMS (American Board of Medical Specialties) recognized board certification in 1974. Currently, fellowship training and ABMS-recognized board certification are offered to graduates of emergency medicine, pediatrics, and occupational medicine residencies. The American Board of Emergency Medicine has administered the certification exam since 1994.

Currently, a majority of the 300 to 400 board-certified medical toxicologists in the US are primarily trained in emergency medicine (as are 95% of the current medical toxicology fellows). Their scope of practice is varied. Some practice primarily in poison centers, providing care to poisoned patients through bedside medical consultation, phone consults with health professionals, and medical backup to SPIs. Other toxicology practitioners have their own medical toxicology inpatient service, admitting patients to the ward and intensive care units primarily. Some specialize in occupational and environmental toxicology and consult with or work at industry or governmental agencies such as the Agency for Toxic Substances Disease Registry of the Centers for Disease Control and Prevention (CDC). Almost all medical toxicologists can provide outpatient consultation to patients concerned about toxicological related issues. Because of the primary training of most of its practitioners, many of the poison centers in the US are located within emergency medicine department administrations at university medical centers.

POISON CONTROLTODAY

Today, there are 62 nationally certified centers in the US. Criteria used for AAPCC certification are listed in the Sidebar. There are three primary roles of a poison control center: community service, health care professional service, and healthcare expenditure reduction.

Community Service

Poison centers provide 24-hour access to all community members, at no cost to the caller, for questions regarding potential toxic exposures, pill identification, drug information, and assessment of environmental and occupational exposures. The majority of calls to poison centers result from acute, unintentional ingestions of single substances by children ages 1 to 5. Analgesics, cleaning substances, and other household products most frequently are involved.5

In 2003, the entire US population (294.7 million) had access to poison center services, and 2,395,582 human exposures were reported to TESS. The ratio of eight exposures for every 1,000 population has remained relatively constant since data were first collected and centralized by TESS in 1 983.5 More than half of poison center contacts by the community represent a worried parent of a young child with an exposure. The vast majority of cases (75% or more) are managed by the poison center staff with the patient at home.5 This service reassures parents and prevents unnecessary phone calls to pediatricians and visits to emergency departments or primary care offices. Surveys show that 43% to 76% of callers to poison control would have sought care at a medical facility (most in emergency departments) if the center did not exist6'7 A nationwide toll-free number has been established (1-800-222-1222), facilitating immediate access to a local poison center from anywhere in the US.

All centers provide community education to help prevent poisonings. Each center has staff members dedicated to community outreach. Such activities may include health fairs, lectures to school, community, or hospital groups, and the provision of educational leaflets, magnets, and stickers to targeted populations (such as families with toddlers).

Finally, through TESS, poison center data from around the country are collected and analyzed in real time. This unique ability, termed "toxicosurveillance," has made the US poison control system an important tool in the struggle against chemical and biologic domestic terrorism, as well as an indicator of impending environmental or infectious disasters, such as a chemical spill or an influenza pandemic.

Healthcare Professional Service

In 2003, poison centers assisted medical professionals in the care of 525,710 patients with toxic or potentially toxic exposures (22% of all human exposure calls to centers).5 While the majority of poisoned patients recover with only supportive care, consultation with a medical or clinical toxicologist streamlines medical evaluations, decreases hospital length of stay, increases patient safety, and reduces liability. Around-the-clock availability of a toxicologist is invaluable. More than 80,000 new synthetic chemicals have been developed and dispersed globally in the past 50 years.4'8 Toxicologists remain up-to-date on new chemicals and drugs, recent outbreaks, and drug interactions, freeing primary care managers, hospitalists, and critical care specialists from that primary responsibility.

Outpatient evaluation of poisoned or potentially poisoned patients also is available through most poison centers. This is most applicable in the fields of occupational toxicology and workman's compensation claims.

Healthcare professionals at all levels have received outstanding education in the care of poisoned patients through training rotations at their poison centers. This is a requirement for most pharmacy doctorate candidates and a majority of emergency medicine residency programs and is a popular elective in pediatrics and internal medicine.

Healthcare Expenditure Reduction

A 1992 study showed that poison centers, by conservative estimates, save $6.50 in medical costs for every $1 spent on poison center operations.9 This estimate was based on the costs incurred from unnecessary healthcare facility visits during a time when a local poison center was temporarily unavailable. This estimate does not take into account any improvement in patient outcomes due to medical toxicologist consultation, likely which would have improved the costbenefit ratio further.

For the 62 poison centers in the US, expenses for personnel, telecommunications, and equipment average $1.38 million per center per year (range: $117,000 to $6.89 million). Total costs for all poison centers approximate $100 million per year.10 Funding for poison control centers is fragmented, with 30 separate funding sources across the country (Figure). Poison centers must spend significant time and effort raising revenue. As financial pressure on state governments and healthcare facilities has risen, the reliability of these sources has become tenuous. 10 This has been the primary force behind recent poison center closures.

States attempt to ensure their respective populations are served by poison centers through an array of configurations, although some lack an adequate population and tax base to support their own center. These states typically contract with a neighboring state for those services. Thus, a single poison center might provide coverage to multiple states and a vast geographic area. Alternatively, other states mandate that their populace be served by multiple centers due to population density or a desire for more local involvement of the centers. The most common situation is for a state to support its own single poison center.

LOOKING AHEAD

Recently, the Institute of Medicine (IOM) was commissioned by the Health Resources and Services Administration (HRSA) to evaluate the US poison control system and recommend the steps needed for long-term stability. Published in 2004, the IOM Report provided a thorough evaluation of the current system. It found that poisoning remains a significant health threat to the US population, that poison centers suffer from fragmented and insufficient funding while clearly reducing healthcare expenses, and that there is clear value in maintaining a stable, regional poison control system throughout the US.10

One of the strongest recommendations made by the IOM was that Congress should provide full funding (at least $ 1 OO million per year) for an integrated, nationwide network of poison control centers. Poison centers currently spend too much time fund-raising in lieu of clinical services. Other recommendations:

* All poison centers should perform a defined set of core activities supported by federal funding. These include phone consultation; chemical and biologic terrorism preparedness; capturing and reporting exposure data; training staff, physicians, and pharmacists; and conducting quality improvement activities.

* The US Department of Health and Human Services (DHHS), along with the states, should ensure a poison prevention and control system that is fully integrated within national, state, and public health infrastructure.

* Poison centers should collaborate with state and local health departments to develop, disseminate, and evaluate public and professional education activities.

* HRSA should commission a systematic management review of poison centers to optimize cost and efficiency fully.

* An external, fully independent body should be responsible for certifying poison centers and specialists in poison information.

* DHHS should educate health care providers on the status of poison control center activities as a part of public health, thus exempting them from the many limitations placed on the sharing of patient information by the Health Insurance Portability and Accountability Act (fflPAA).

* The CDC should ensure that real-time TESS data be made available to all poison centers and local, state, and federal public health units at no additional cost.

* The CDC, along with HRSA and the states, should fully evaluate the use of TESS as a source of case detection for all-hazards surveillance.

* Federal grants for research in areas such as poisoning epidemiology and prevention, as well as population-based outcomes of general and specific poisons, should be made more available.

Whether or not poison control centers survive during times of budgetary and tax cuts will depend on the federal government's willingness to fund the system fully, as recommended by the IOM. Consolidation of poison centers due to financial pressures into large, multistate regional centers would be unfortunate and shortsighted. Hospitalists and primary care managers are more comfortable discussing a case with people whom they know, deal with routinely, and often see at the patient's bedside, rather than with an anonymous voice on the telephone from a distant location.

SUMMARY

Poison centers save money and lives. Individual patients and their doctors benefit from local poison center availability, as do healthcare facilities and insurance companies. All have a stake in a stable poison control system.

It is likely that the greatest contribution of poison control centers to society has yet to be realized. Poison control centers already possess an efficient, realtime surveillance mechanism (TESS). With increased funding, this can be expanded and made more available outside the poison control community. TESS can be used to detect chemical releases or attacks and environmental and infectious disease outbreaks as they occur - long before individual healthcare providers could connect the dots.

In conclusion, while the value of a nationwide poison control system to society is well recognized, its future is not as clear. Establishing a stable system to monitor and treat poisonings in the US will take political will at the local, state, and federal levels to ensure full funding for years to come.

REFERENCES

1. Timbrell J. Introduction to Toxicology. London, England: Taylor and Francis; 1989.

2. Webster's Third New International Dictionary. Springfield, MA: Merriam-Webster, 2002.

3. Wax P. Historical principles and perspectives. In: Goldfrank, LR, Flomenbaum NE, Lewin NA, Rowland MA, Hoffman RS, Nelson LS, eds. Goldfrank's Toxicologie Emergencies. 7th ed. New York, NY: McGraw-Hill; 2002: 1.

4. Woolf A. Challenge and promise: the future of poison control services. Toxicology. 2004;198(103):285-289.

5. Watson WA, litovitz TL, Klein-Schwartz W, et al. 2003 annual report of the American Association of Poison Control Centers Toxic Surveillance System. Am J Emerg Mea. 2004;22(5): 335404.

6. Kelly NR, Ellis MD, Kirkland RT, Holmes SE, Kozinetz CA. Effectiveness of a poison center impact on medical facility visits. Vet Human Toxicol. 1997;39(1):4448.

7. Darwin J, Seger D. Reaffirmed cost-effectiveness of poison centers. Ann Emerg Med. 2003;41(1): 159-160.

8. Landrigan PJ, Garg A. Chronic effects of toxic environmental exposures on children's health. J Toxicol Clin Toxicol. 2002;49:449-56.

9. Miller TR, Lestina DC. Costs of poisoning in the United States and savings from poison control centers: a benefit-cost analysis. Ann Emerg Med. 1997;29(2):239-245.

10. Institute of Medicine. Forging a Poison Prevention and Control System. Washington, DC: National Academies Press; 2004.

10.3928/0090-4481-20051201-14

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