2008 presentation on poison center services to Northwestern EM Residency

1. Illinois Poison Center
A Public Health Information and
Education Service

2. Why Poison Center Services?

4. Overview of the IPC
 History of Poison Centers in Illinois
 Mission
 Emergency Call Center Services
 Public Education
 Professional Education
 Public Health – Reporting, Surveillance
 Research

5. 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

6. 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

8. 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

9. Illinois Poison Center and MCHC
Program of Metropolitan Chicago Healthcare
Council (MCHC)

10. 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)

11. 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

12. Mission
The 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

13. Emergency Call Center
 Available 24 hours a day, 365 days
a year via toll-free number
1.800.222.1222

14. 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

15. 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

16. 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)

17. 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

18. Emergency Call Center
36% Increase in Service since 2000
0
20000
40000
60000
80000
100000
120000
2000 2002 2004 2006
Tot al Calls

19. Emergency Call Center Services
HCF calls increased 21% since 2003
YearTotals
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
2001 2002 2003 2004 2005 2006
YearTotals

20. 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

21. IPC CSPI exam scores
IPC scores average = 91% (101/110)
National average = 75% (82/110)

22. 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.

23. 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

24. 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

25. 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

26. 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)

27. Public Education
 Goal #1 is to provide poison
prevention to families and
communities to create healthier and
safer communities

28. 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.

29. Public Education
 Service Region Size is a
significant barrier
 State of Illinois
 12.7 million people
 55,000 square miles

30. 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

32. 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)

33. 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
TV
Radio
Web
12 hospital
educators in
various
regions in
the state
“Online
educators”
Faith-based
Ethnic
Professional
Government

34. 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

35. Media Processes – press
releases, interviews, “mentions”
(print)
0
50
100
150
200
250
300
350
400
2001 2003 2005
Releases
I nterview s
Mentions

36. Media – web utilization (page
views)
0
50000
100000
150000
200000
250000
300000
2004 2005 2006
Public
Professional
Educator
Total

37. 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’

38. 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

39. Volunteer Educator Approach
Educators Trained
0
200
400
600
800
1000
1200
1400
1600
1800
2000
2002 2003 2004 2005 2006
Online
Satellites/IPC
40%
33%

40. Outreach Events per year
IPC Outreach Events
0
200
400
600
800
1000
1200
1400
1600
1800
1
2002
2003
2004
2005
2006
20%
34%
70%
26%

41. Satellite Events
0
200
400
600
800
1000
1200
1400
1600
1800
2001 2002 2003 2004 2005 2006
Satellite and I PC
events
Online Educator
Events
Total Events

42. Satellite People Reached
0
50000
100000
150000
200000
250000
2001 2002 2003 2004 2005 2006
Satellites and I PC
Online Educators
Total

43. 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

44. 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’

45. Community and School
Education

46. So, that is a lot of effort…

47. Case volume over time
0
20000
40000
60000
80000
100000
120000
2000 2002 2004 2006
Exposures
Total Calls

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

49. Poison Data for Illinois
0
2000
4000
6000
8000
10000
12000
14000
16000
2001 2002 2003 2004 2005 2006
I n/ enroute to HCF
Treated and
Released

50. % Treated and Released of
In/Enroute to HCF
15% decrease in non-emergent poisoning that
presents primarily to ED.
41
42
43
44
45
46
47
48
49
50
2001 2004
%
t r eat ed
and
r eleased

51. Causality
 Control group: National data?
 Change in number of severe poisonings
(acuity)?
 Population/Demographic change?
 Change in training of staff?
Still intriguing Data

52. Latino Outreach Results with
Sinai Community Institute
 Total calls increased
18%
 Calls from hospital
decreased 3%
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
2002 2004 2006
Tot al
Calls
Calls
from
HCF

53. 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?
0
200
400
600
800
1000
1200
1400
1600
2002 2004 2006
Calls
from HCF
Treat ed
and
Released

54. Latino Outreach Results with
Sinai Community Institute
 23% reduction in
pediatric HCF
visits
 28% reduction in
Pediatric T and R
0
50
100
150
200
250
300
350
2002 2004 2006
Peds calls
from HCF
Treat ed
and
Released--
Pediat ric

55. Latino Outreach Results with
Sinai Community Institute
 Essentially
unchanged from
baseline of
2002/2003
0
100
200
300
400
500
600
700
2002 2004 2006
Medical
Admissions
all ages

56. 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
0
5
10
15
20
25
30
35
40
45
50
2002 2004 2006
Pediatric
admissions

57. 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

58. 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

59. 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

60. 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

61. 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

62. Surveillance
 Software-driven Surveillance of National
Poison Database System (NPDS)
 Individual Reporting: High index of
suspicion, clinical awareness
 Driven by experience

63. 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

64. 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)

65. 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”

66. 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

67. 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

68. 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

69. 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

70. 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

71. Research
 Current database with 600,000 cases of
poisoning
 Cases are easily retrieved and examined

72. 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

73. Research Example

74. 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

75. 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

76. Heroin Body Stuffers
 Resurrection Program
 65 heroin body stuffers
 6 (9%) symptomatic, all within 1 hour of
ingestion
 3 (4.6%) needed naloxone

77. 2007 ICEP Resident Research2007 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.

78. 0
50
100
1 4 7 10 13 16 19 22 25 28 31 34 37 40
Initial (mgc/mL) Highest (mcg/mL)
InitiallyInitially supratherapeuticsupratherapeutic concentrationconcentration
and continued to rise > 12 mcg/mLand continued to rise > 12 mcg/mL

79. InitiallyInitially therapeutictherapeutic concentration andconcentration and
continued to rise > 12 mcg/mLcontinued to rise > 12 mcg/mL
0
20
40
1 2 3 4 5 6 7 8 9 10 11
Initial (mcg/mL) Hightest (mcg/mL)

80. InitiallyInitially subtherapeuticsubtherapeutic concentrationconcentration
and continued to rise > 12 mcg/mLand continued to rise > 12 mcg/mL
0
10
20
30
1 2 3 4 5
Initial (mcg/mL) Highest (mcg/mL)

81. Caffeine

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

83. 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

84. Potential Examples
 Triage criteria: Do they change
practice? Value?
 Epidemiology of poisoning
 New trends
 Emerging trends in drug abuse
 Coricidin
 Alternate routes of exposure

85. Research
Medical Admissions all Poisoned Patients
0
1000
2000
3000
4000
5000
6000
7000
8000
2002 2003 2004 2005 2006 2007
Year
numberofadmissions
2002
2003
2004
2005
2006
2007

86. In summary, the IPC is the place
to call

87. But it is so much more…
It is a comprehensive public health
information and education service