Poison Center Services 2008

Illinois Poison Center

A Public Health Information and Education Service

Why Poison Center Services?

Overview of the IPC History of Poison Centers in

Illinois Mission

Emergency Call Center Services Public Education Professional Education Public Health – Reporting,

Surveillance Research

Poison Center History 1953

First poison control center in the nation: Rush University

Early 1960’s Over 100 poison information

centers in Illinois American Association of Poison

Control Centers (AAPCC) formed

Poison Center History 1980s

Poison centers around the state gradually closed

1990 Three centers left in Illinois None certified by AAPCC

By 1996 Two centers had closed Rush center announced plans to close

Illinois Poison Center October 1997

50% of funding from State of Illinois 50% of funding raised privately

and/or from hospitals Core functions

Call center for healthcare professionals and general public

Professional education

Illinois Poison Center and MCHC

Program of Metropolitan Chicago Healthcare Council (MCHC)

Poison Center History 1997

Rush poison center transitioned to Metropolitan Chicago Healthcare Council

Organized as a not-for-profit 501(3c) under MCHC/Chicago Hospital Council

Name changed to Illinois Poison Center (IPC)

Illinois Poison Center 1998: Certified by AAPCC in 1998

Only AAPCC-certified regional poison center in Illinois

Operational requirements 24/7/365 call center

Professional education requirements Staff requirements

Certified specialist in poison information (CSPI)

Medical toxicologist Medical director On-call staff support

Education and outreach requirements

MissionThe Illinois Poison Center is dedicated to reducing the incidence and injury of poisoning in our communities through immediate expert telephone recommendations, innovative public and health care professional education and focused research.

Our vision is an Illinois that no longer suffers from the harm of poisoning

Emergency Call Center

Available 24 hours a day, 365 days a year via toll-free number

1.800.222.1222

Call Center Services Over 107,000 calls in 2006 Almost 87,400 exposures Over 15,000 calls from health care

providers (17% of calls); most from hospital based personnel We are consultants to healthcare

professionals on toxicology and poisoning

AAPCC Clinical Staff Requirements

Specialists in Poison Information Nurses, Pharmacist, Physician Assistants and

Physicians Poison Information Providers

IPC prefers Pharm. Tech, Paramedics, BA/BS in a life science and health care experience

Medical Directors Board certified in EM, Pediatrics or Preventative

Medicine Board Certified in Medical Toxicology

Illinois Poison Center

Current Clinical Staffing:

16 Pharmacists and nurses (13 FT/3 PT)

7 Poison information providers (6 FT/1 PT)

3 Medical directors (1 FT/ 2 PT)

Types of Calls The IPC provides treatment advice

and information for overdoses, medication errors, occupational accidents, hazardous material incidents, venomous bites and more

51% of exposures involve children under the age of 6 years of age

Emergency Call Center 36% Increase in Service since 2000

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Emergency Call Center ServicesHCF calls increased 21% since 2003

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Emergency Call Center Services

IPC Staff that answer HCF calls have all been passed a national exam in toxicology and are considered Certified Specialists in Poison Information

Stability, additional training, monthly educational lectures add to depth of experience of staff

IPC CSPI exam scoresIPC scores average = 91% (101/110)

National average = 75% (82/110)

Value of Call Center Services Health Resources and Services

Administration (HRSA) estimates that for every $1 dollar spent on poison control services $7 dollars in health care costs are saved

IPC budget ~4,000,000 so about $28,000,000 saved

Caveat: based on 1980’s and early 1990’s data.

Value of Call Center Services

90% of calls from general public are managed at home with simple first aid instructions

70% of callers would seek healthcare if poison center services are not available

Estimated ED cost of $1,000 Potential savings: $45,000,000

Value of Call Center Services

When poison center services not available, admissions increase by 16%

10,843 admissions in 2005 per hospital discharge data

Extrapolation of an additional 1700 admissions

Average cost of admission from poisoning is $10,843

Potential savings: over $18,000,000

Value of Call Center Services

Length of Stay (LOS) New Jersey Study (2007) showed:

Admitted patients where poison center was consulted had mean LOS of 3.9 days

Admitted patients where poison center was NOT consulted had mean LOS of 6.9 days

Hospital stay for poisoning $1,500 per day average per IDPH data

Potential savings: $56,000,000

Value of Call Center Services

Poison Centers save society money through:

Preventing unnecessary healthcare visits

Decreasing admissions to hospitals Decreasing the LOS at hospitals

Estimated potential savings for Illinois is ~$119,000,000 ($30 saved for every $1 spent)

Public Education Goal #1 is to provide poison

prevention to families and communities to create healthier and safer communities

Public Education Goal #2 is to raise awareness of the

IPC services so as to maximize the value of the call center services in decreasing medical costs.

Public Education

Service Region Size is a significant barrier State of Illinois 12.7 million people 55,000 square miles

Theory of Change Problem

Low utilization of poison center services Accidental poisoning a threat to community

Historically little poison prevention education led by Illinois Poison Centers

Strategies Media, Regional Education Centers,

Volunteer Educators, Professional/community organizations

Assumptions Little history of poison prevention education

led by poison centers, “space” could be filled with good programs and leadership

Theory of Change Planning Tool

Project A + Project B + Project C = Outcome D

• A+B+C are based on someone else’s research, collective experience, historical principles, preponderance of evidence

• A, B and C are the most compelling strategies to achieve and outcome D (success of the program)

IPC theory of change strategy

A + B + C + E = D

Media Hospital Satellite Network

Volunteer Educators

Individuals,Community and Professional organizations

1) Increased awareness 2)Decreased unintentional poisoning

Newspaper TVRadioWeb

12 hospital educators in various regions in the state

“Online educators”

Faith-basedEthnicProfessionalGovernment

Measure and quantify the processes

It is assumed that processes will make a difference over time

Time may be months, years, generations

The only thing one can control is the process and hope the assumptions are correct

Media Processes – press releases, interviews, “mentions” (print)

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Media – web utilization (page views)

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PublicProfessionalEducatorTotal

Media Broad ranging – 100’s of thousands if

not millions of people read an article in print, web or hear about the poison center on radio or TV

Passive Difficult to measure at an individual

basis Constant updating to ‘new threats’

Hospital Satellite System Regional Hospital based education

centers throughout the state Train the trainer approach encouraged Educators are regional experts for their

volunteer educators and “online” educators

Quarterly meetings – teleconference One annual face-to-face all day meeting

Beginning to encourage the interaction with more community groups

Volunteer Educator Approach

Educators Trained

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Online

Satellites/IPC

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33%

Outreach Events per yearIPC Outreach Events

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Satellite Events

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Satellite and IPCeventsOnline EducatorEventsTotal Events

Satellite People Reached

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Satellites and IPCOnline EducatorsTotal

Community, professional and government organizations

Children’s librarians School Nurse associations EMS DCFS WIC Casa Central HispanoCare Over 20 additional community

organizations throughout the state

Types of events EMS group that has poison prevention

booth at local fairs, parade, community celebrations.

Pharmacy schools and students School Nurses who provide poison

prevention during NPPW Librarians who have a poison

prevention ‘story time theme’

Community and School Education

So, that is a lot of effort…

Case volume over time

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Penetrance changes by geography (more successful in small metro and rural areas)

Poison Data for Illinois

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In/ enroute to HCF

Treated andReleased

% Treated and Released of In/Enroute to HCF

15% decrease in non-emergent poisoning that presents primarily to ED.

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%treatedandreleased

Causality Control group: National data? Change in number of severe

poisonings (acuity)? Population/Demographic change? Change in training of staff?

Still intriguing Data

Latino Outreach Results with Sinai Community Institute

Total calls increased 18%

Calls from hospital decreased 3%

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TotalCalls

CallsfromHCF

Latino Outreach Results with Sinai Community Institute

Treated and Released decreased 17% from 2002/2003 baseline

Total calls increased 18%, T and R decreased 17%

Poison prevention vs. calling IPC?

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Callsfrom HCF

TreatedandReleased

Latino Outreach Results with Sinai Community Institute

23% reduction in pediatric HCF visits

28% reduction in Pediatric T and R

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TreatedandReleased--Pediatric

Latino Outreach Results with Sinai Community Institute

Essentially unchanged from baseline of 2002/2003

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MedicalAdmissionsall ages

Latino Outreach Results with Sinai Community Institute

36% reduction in pediatric admissions from poisoning

State numbers for control unchanged

Decrease in ED visits and Admissions = >$219,000 saved from baseline

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Pediatricadmissions

Theory of Change

What works the best? Not sure if media, satellites or

community organizations is most cost effective

Community Organizations may be better partners in hard to reach populations

Easier to raise foundation money if working with community organizations

Professional Education

Expertise of Poison Center Staff in field of Poisoning an Toxicology

Undergraduate and Graduate Education Medical students Pharmacy students Medical and Pharmacy Residents

Continuing Education for practicing professionals Advanced HAZMAT Life Support (AHLS) Bioterrorism Training and Curriculum Development Program

(BTCDP) Individual Lectures for institutions

Undergraduate Education Medical and Pharmacy Students can

come to IPC for 2 weeks to 6 weeks at a time 12 per year at IPC 26 per year with Toxikon (affiliated

educational organization) Individual lectures at Pharmacy and

Medical Schools About 12 per year at 3 different schools of

pharmacy and 3 school of medicine

Post Graduate Education 80 to 100 medical residents,

pharmacy residents and fellows rotate through Toxikon and the IPC every year

Most emergency medicine residencies in Chicago send their residents for education with the IPC and Toxikon

Continuing Education Advanced HAZMAT Life Support (AHLS)

577 providers Trained since 2002 Bioterrorism Training and Curriculum

Development Program (BTCDP) 624 people educated since 2004

Individual Lectures (~ 10 to 30 per year) to institutions that request presentations to staff

Surveillance Software-driven Surveillance of

National Poison Database System (NPDS)

Individual Reporting: High index of suspicion, clinical awareness Driven by experience

Software surveillance

All exposure calls are logged into an electronic program with two functions

One function is the medical record: Recorded history, physical, assessment

and plan The second is database

All products are coded, route of exposure, location of exposure, clinical effects noted

Software Surveillance The coded fields from every poison

center in the U.S, are uploaded every 20 minutes to New Jersey (essentially real-time)

The data is then analyzed with software developed in conjunction with the CDC (BIOSENSE)

Software Surveillance National Surveillance

three standard deviations from moving 14 day average for past three years creates a notification

Total Call Volume (by center) Human Exposure Volume (by center) Clinical Effects

Procedure Alert at national office

National office investigates data If signal is worrisome, local poison center

contacted for ‘follow back”

Individual Reporting Public Health Reporting by individuals

Astute clinician realizes something is out of the ordinary and reports it to other agencies

Recognition can occur in various points of patient care

Examples of Food Borne Illness Reporting

March 2004 Call to Illinois Poison

Center from HCF re: 2 individual with severe muscle breakdown

Recent ingestion of Buffalo Fish

Dx: Haff Disease

Examples of Food Borne Illness Reporting

Fall, 2006 Call from HCF regarding

patient with numbness, tingling and reversal of hot and cold

Patient recalls eating grouper at restaurant that night

Dx: Ciguatera Poisoning

Examples of Food Borne Illness Reporting

May, 2007 Call from HCF re: patient

who had weakness, near paralysis after ingestion of “puffer fish”

Dx: Tetrodotoxin poisoning

FDA recall

Winter 2005 - 2006 Bootmate sealant Exposures reported to PCC led to

respiratory symptoms ranging from cough to pneumonitis to pulmonary edema

Initially noted by Detroit Poison Center Investigation showed over 179 exposures

with mild to severe clinical effects in midwest and eastern U.S.

Product recalled

Research Current database with 600,000 cases

of poisoning Cases are easily retrieved and

examined

Research Answer questions that have not yet

been answered Change the knowledge base of medicine Change the knowledge base of the public Change the practice of medicine

Research Example

Crack Cocaine Body stuffers

Crack Cocaine Body Stuffers 50 KUB No Foreign Body seen on x-ray In the Chicago area, x-rays are of no

value in the diagnostic work up of a crack cocaine body stuffer Packaging in Chicago may be different

than the packaging in other parts of the country

Research examples Rodenticides – long acting

superwarfarins 750 cases, no bleeding 48 cases with f/u INR, 2 abnormal, both

lab error No cases of true coagulopathy

Heroin Body Stuffers Resurrection Program

65 heroin body stuffers 6 (9%) symptomatic, all within 1 hour of

ingestion 3 (4.6%) needed naloxone

2007 ICEP Resident Research 2007 ICEP Resident Research Award WinnerAward Winner

Retrospective case series All carbamazepine exposures reported

to our regional poison center between January 1, 2001 and December 31, 2005 were investigated.

Inclusion criteria were all acute poisonings with concentrations greater than 12 mcg/mL at any given time.

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Initial (mgc/mL) Highest (mcg/mL)

InitiallyInitially supratherapeuticsupratherapeutic concentration and continued to rise concentration and continued to rise > 12 mcg/mL> 12 mcg/mL

Initially Initially therapeutictherapeutic concentration concentration and continued to rise > 12 mcg/mLand continued to rise > 12 mcg/mL

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Initial (mcg/mL) Hightest (mcg/mL)

Initially Initially subtherapeuticsubtherapeutic concentration and continued to rise concentration and continued to rise > 12 mcg/mL> 12 mcg/mL

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Caffeine

Research – why? Change the practice of medicine Improve outcomes Improve public health

Research – Why? RRC requirement Career choices

Academic vs. Community Practice Medical Toxicology Fellowship

Change the useful knowledge base, change the practice of medicine

Cool Trips: North American Congress of Clinical Toxicology

2008 Toronto 2009 San Antonio 2010 Denver

Potential Examples Triage criteria: Do they change

practice? Value? Epidemiology of poisoning

New trends Emerging trends in drug abuse

Coricidin Alternate routes of exposure

ResearchMedical Admissions all Poisoned Patients

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In summary, the IPC is the place to call

But it is so much more…

It is a comprehensive public health information and education service