ORGANISATION & RESOURCES

CLINICAL PHARMACY

POISON INFORMATION

HISTORY

In 1930’s – Louis Gdalman established the framework for the first poison control center at Ruspresbyterian-St.Luke’s hospital.

In 1950’s – Missouri pharmacist, Homer George lead a poison prevention campaign in his hometown that eventually grew into a National poison prevention week

In 1980’s – Dr. Joseph Veltri chaired a committee to improve poison center data collection. This project grew into the Toxic Exposure Surveillance System(TESS) the largest poisoning database in the world.

In addition pharmacists provide a key leadership roles in:

American Association of Poison Control Centers

American Academy of Clinical Toxicology

The National Poison Prevention Week Council

American Board of Applied Toxicology

Poison centers were established for two reasons:To provide rapid access to information valuable in assessing

and treating poisoningsTo assist with poison prevention.

GOALS:

To provide comprehensive, accurate and timely information to their clients

To enhance the medical care of patients Drug Information Center also exist with same goals as Poison Information center

Poison Information Center

CLIENTELE 88% poison center calls

are placed by public

CALL VOLUME 103 calls per day, it

ranges from 33 to 213 calls per day.depending upon service population size,poison center awareness in that area,poisoning rates.

Drug Information Center

9-10% calls are placed by public,but mostly by health care professionals.

Fewer than 7 calls per day

DIFFERENCES BETWEEN DIC & PIC

HOURS OF OPERATION/COST Operates 24hrs a day

year round More expensive

STAFFING They use a wider variety

of health care professionals

FUNDING Public funding

Operates 9AM-5PM

Less expensive

They rely on pharmacists

Sponsored by hospitals or medical centers

RESPONSE TIME Average response time is

5min.

CALL COMPLEXITY Less complex

REFERENCES Broader based reference

collection

DOCUMENTATION Standardized data

collection instrument is present

15-30min or it may extend to days.

More complex

Less than PIC

Not present

The data elements that are currently being tracked through the TESS include:

General epidemiological data- date and time of call, reason for exposure

Caller characteristics- site of caller, city and state

Patient characteristics- age and sex, pregnancy status

Exposure characteristics- substance, route of exposure, site of exposure

Clinical course- clinical manifestations and therapeutic interventions

HOW TO ORGANIZE A POISON CENTERPoison center expenses and potential revenues are directly tied to

call volume.Therefore one of the most important considerations in organizing

a poison center should be the “ideal human exposure call volume”.

Maximal personnel, facility, and reference expenses can be predicted.

PERSONNEL

1. Medical Director

2. Poison information specialists

3. Manager or Supervisor

1. MEDICAL DIRECTOR: Ultimately responsible for all medical aspects of the poison center’s operation. The non physician poison information specialists provide medical care under the direction and authority of the program’s medical director.

DUTIESRegular review and authorization of all poisoning

management protocols.Authorization of poison center policies and proceduresParticipation in staff trainingProvision of on-call clinical support for poison center

staffParticipation in quality assurance activitiesLiaision with local medical societies, physicians, EMS,

state and federal agencies

Promotion of researchCoordination of professional education effortsMost poison center medical directors are board certified in

internal medicine, pediatrics, or family practice. One indicator of expertise in medical toxicology might be

board of certification through the Medical Toxicology Subspeciality Examination offered jointly by the American Board Of Pediatrics, American Board Of Emergency Medicine and American Board Of Medical Toxicology.

According to AAPCC criteria for certification as a Regional Poison Center, the medical director should devote 50% of his or her professional activities to toxicology and spend atleast 10hrs per week working on poison center related activities.

If the medical director is performing the duties outlined previously, it is likely that his or her time commitment will be met.

2. POISON INFORMATION SPECIALISTS They directly interact with the public and health care

professionals. Poison information specialists must be both clinicians and

counselors. They must elicit a complete history, correctly assess the potential severity of exposure using the most appropriate management plan to the caller.

In addition, poison information specialists must be able to focus callers who are unable to give cohesive history.

Specialists should be able to communicate in a calm , reassuring manner at all levels of education.

Both nurses and pharmacists are suitable poison information specialists.

A national certification examination for specialists in poison information is offered each may through the American Association Of Poison Control Centers.

To take the examination , specialists must provide evidence that they have handled 2000 poison exposure cases and have worked 2000 hrs in poison center.

In addition, they must have the approval of their center’s medical directors

Certification is maintained by continuing to work atleast 8 annualized hours per week in poison center and passing the certification exam at atleast every 7 years.

The American Association Of Poison Control Centers mandates that specialist must work a minimum annualized average of 16hrs per week. This drops to 8 hours a week once they have been certified.

Many centers tend to use part-time specialists working an average of 20 hours per week.

On-call responsibilities may be integrated into the schedule so that unexpected coverage is handled fairly and efficiently.

The on-call person may be paid a minimum hourly base rate. If he or she is called into the work, the person is paid one and one-half times the regular rate of pay.

3. MANAGER/SUPERVISOR The manager is responsible for administrative aspects of the

center’s operation. Ideally this person has established clinical, administrative and

supervisory skills

DUTIESBudgetingPurchasingStaff scheduling, supervision, trainingMaintenance of continuous quality improvement programDevelopment of department policies and proceduresPreparation of administrative reportsMedia responseProfessional education

The manager/supervisor should know all aspects of the poison center’s program and have a complete knowledge base in clinical toxicology.

The manager should be able to assist specialists during the assessment of difficult cases and substitute for specialists when the need arises.

Many programs use pharmacists with postdoctoral training in clinical toxicology to fill this position, however, experienced nurses and physicians work equally as well.

Certification through the American Board of Applied Toxicology or in the case of physicians, through the Medical Toxicology Sub-speciality Examination provides evidence of an ongoing interest and expertise in clinical toxicology.

PUBLIC EDUCATION COORDINATOR Ideally this coordinator has a background in education and media

communications and experience as poison information specialist

The duties of public education coordinator may include:

Development, distribution and evaluation of poison prevention programs and materials

Coordination of regularly occuring public education messages through the media.

Networking with schools and other organizations to provide cost- effective public education.

Coordination of poison prevention through poison information specialists.

OTHER PERSONNEL Secretarial support Volunteers Toxicology professionals Advisory boards

IDEAL LOCATIONS

Emergency department Next to a large medical library Hospital pharmacies Schools of pharmacy DIC

The work area should be designed to allow 100-200 square feet per work station and should be situated in a relatively quiet situation.

Some poison centers prefer to separate work stations into walled cubicles to further eliminate peripheral distractions.

Because stress is the primary draw back to working in a poison center, the work area should be designed to reduce stress as much as possible.

Windows and natural lightning, ergonomic furniture, aquariums and soothing colors are starting points.

The poison center medical director’s and manager’s offices should be adjacent to the main work area rather than in a different part of the facility,so,these individuals can provide constant support

Portable telephones, call-answering devices and call forwarding to a cellular telephones are less expensive alternatives that provide varying degrees of functionality.

EQUIPMENT Telephone

Personal computers

Modem

Facsimile machine

Refrigerator and microwave

File cabinets and shelving

Generator

RESOURCESMicromedex’s poisindex(a database of more than 8,00,000

household products, chemicals, and medications)

General product formulations are found in Clinical Toxicology Of Commercial Products by Gosselin, Smith, and Hodge.

In addition they often maintain manufacture files with recent product formulations

Information required stems from a specialized branch of toxicology

Internal protocols, journals, medical literatures

POLICIES AND PROCEDURES

It frames the poison center’s methods of operation. It clarifies the direction of the program and relates each operational

facet and each other’s position in the poison center to the main operational directives

At a minimum, each policy and procedure should be dated and signed by the medical director indicating that they have been reviewed and approved by this individual.

In some settings there may be additional approvals required It is useful to maintain system for tracking policies and procedures

so that when questions arise there is a simple way to determine operational policies existing at any given moment.

Database management programs simplify much of this record keeping and reduce record storage requirements.

TRAINING OF SPECIALISTS

The goals of training are to establish a comfortable telephone risk assessment routine, while gradually building the specialist’s knowledge base in clinical toxicology and fine-tuning telephone communication skills.

Most poison centers spend between 6 and 8 weeks training specialists.

The format varies depending on the center’s call volume, the staff’s experience, and allocation of resources by the sponsoring institution.

Basic training elements should include a discussion of:

Policies and procedures

Data collection format

Reference use

General poisoning management strategies

Telephone communication technique

Assessment and treatment of common deadly poisonings

THE FUTURE OF POISON CONTROL

The poison information system is rapidly changing. Since its inception 40yrs ago, pharmacy has provided unique leadership and expertise.

As long as medications top the list of substances responsible for poisoning, pharmacy will always be an integral part of the poison information system.

REFERENCE

Drug information-A guide for pharmacists by Patrick M.Malone.

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