Specialists In Poison Information Research Articles

Outgoing initial healthcare facility follow-up call metrics and barriers within a single United States poison center

Introduction Specialists in poison information are responsible for following-up with exposure cases managed at healthcare facilities. However, the amount of time, call components, and barriers met when completing an initial healthcare facility follow-up call in which a large amount of data and clinical recommendations are shared is not well described. Methods A retrospective observational study was conducted by randomizing healthcare facility initial follow-up calls from January to April 2022. One hundred and thirty calls that met the inclusion criteria were randomly selected. We recorded seven unique time intervals within each call. Day of the week, time of day, and variability amongst specialists in poison information were also assessed. Results Initial follow-up calls took a median of 7.2 min. Most (67%) follow-up calls were directed to emergency departments. Barriers to completion of calls were most commonly due to the healthcare reporter being busy (37%) and specialists in poison information being placed on terminal hold (30%). There was variability between specialists in poison information in the time for healthcare reporter to share data (P < 0.0001), time for specialists in poison information recommendations (P = 0.0076), and total time (P = 0.0003). Discussion Variability exists amongst specialists in poison information during periods of information exchange, particularly when the healthcare reporter is providing information and subsequently when the specialist in poison information is providing recommendations. Barriers to completing calls centered around healthcare reporter being busy or the specialist in poison information being placed on a terminal hold. There was no correlation with the time or day of the week. Conclusions With notable variability in these calls during periods of intense communication of data and treatment recommendations, there are likely opportunities for specialists in poison information and poison center directors to work together to address variability and overcome barriers to completing initial hospital follow-up calls. Further studies to evaluate variability amongst specialists in poison information are the next steps in understanding this complex topic.

Use of large language models to optimize poison center charting

Introduction Efficient and complete medical charting is essential for patient care and research purposes. In this study, we sought to determine if Chat Generative Pre-Trained Transformer could generate cogent, suitable charts from recorded, real-world poison center calls and abstract and tabulate data. Methods De-identified transcripts of real-world hospital-initiated poison center consults were summarized by Chat Generative Pre-Trained Transformer 4.0. Additionally, Chat Generative Pre-Trained Transformer organized tables for data points, including vital signs, test results, therapies, and recommendations. Seven trained reviewers, including certified specialists in poison information and board-certified medical toxicologists, graded summaries using a 1 to 5 scale to determine appropriateness for entry into the medical record. Intra-rater reliability was calculated. Tabulated data was quantitatively evaluated for accuracy. Finally, reviewers selected preferred documentation: original or Chat Generative Pre-Trained Transformer organized. Results Eighty percent of summaries had a median score high enough to be deemed appropriate for entry into the medical record. In three duplicate cases, reviewers did change scores, leading to moderate intra-rater reliability (kappa = 0.6). Among all cases, 91 percent of data points were correctly abstracted into table format. Discussion By utilizing a large language model with a unified prompt, charts can be generated directly from conversations in seconds without the need for additional training. Charts generated by Chat Generative Pre-Trained Transformer were preferred over extant charts, even when they were deemed unacceptable for entry into the medical record prior to the correction of errors. However, there were several limitations to our study, including poor intra-rater-reliability and a limited number of cases examined. Conclusions In this study, we demonstrate that large language models can generate coherent summaries of real-world poison center calls that are often acceptable for entry to the medical record as is. When errors were present, these were often fixed with the addition or deletion of a word or phrase, presenting an enormous opportunity for efficiency gains. Our future work will focus on implementing this process in a prospective fashion.

2021 Annual Report of the Kansas Poison Control Center at The University of Kansas Health System.

This is the 2021 Annual Report of the Kansas Poison Control Center (KSPCC) at The University of Kansas Health System. The KSPCC serves the state of Kansas 24-hours a day, 365 days a year with certified specialists in poison information and clinical and medical toxicologists. Encounters reported to the KSPCC from January 1, 2021 through December 31, 2021 were analyzed. Data recorded includes caller demographics, exposure substance, nature and route of exposure, interventions, medical outcome, disposition, and location of care. The KSPCC logged 18,253 total encounters in 2021, including calls from every county in Kansas. A majority of human exposure cases (53.6%) were female. Approximately 59.8% were pediatric exposures (defined as 19 years of age or less). Most encounters occurred at a residence (91.7%) and most were managed there (70.5%). Unintentional exposures were the most common reason for exposures (70.5%). The most common reported substance in pediatric encounters was household cleaning products (n = 815) and cosmetics/personal care products (n = 735). For adult encounters, analgesics (n = 1,241) and sedative/ hypnotics/antipsychotics (n = 1,013) were the most frequently reported. Medical outcomes were 26.0% no effect, 22.4% minor effect, 10.7% moderate effect, and 2.7% major effects. There were 22 deaths. The 2021 KSPCC annual report demonstrated that cases were received from the entire state of Kansas. Pediatric exposures remained most common but cases with serious outcomes continued to increase. This report supported the continued value of the KSPCC to both public and health care providers in the state of Kansas.

Using Surveillance With Near-Real-Time Alerts During a Cluster of Overdoses From Fentanyl-Contaminated Crack Cocaine, Connecticut, June 2019.

In 2019, Connecticut launched an opioid overdose-monitoring program to provide rapid intervention and limit opioid overdose-related harms. The Connecticut Statewide Opioid Response Directive (SWORD)-a collaboration among the Connecticut State Department of Public Health, Connecticut Poison Control Center (CPCC), emergency medical services (EMS), New England High Intensity Drug Trafficking Area (HIDTA), and local harm reduction groups-required EMS providers to call in all suspected opioid overdoses to the CPCC. A centralized data collection system and the HIDTA overdose mapping tool were used to identify outbreaks and direct interventions. We describe the successful identification of a cluster of fentanyl-contaminated crack cocaine overdoses leading to a rapid public health response. On June 1, 2019, paramedics called in to the CPCC 2 people with suspected opioid overdose who reported exclusive use of crack cocaine after being resuscitated with naloxone. When CPCC specialists in poison information followed up on the patients' status with the emergency department, they learned of 2 similar cases, raising suspicion that a batch of crack cocaine was mixed with an opioid, possibly fentanyl. The overdose mapping tool pinpointed the overdose nexus to a neighborhood in Hartford, Connecticut; the CPCC supervisor alerted the Connecticut State Department of Public Health, which in turn notified local health departments, public safety officials, and harm reduction groups. Harm reduction groups distributed fentanyl test strips and naloxone to crack cocaine users and warned them of the dangers of using alone. The outbreak lasted 5 days and tallied at least 22 overdoses, including 6 deaths. SWORD's near-real-time EMS reporting combined with the overdose mapping tool enabled rapid recognition of this overdose cluster, and the public health response likely prevented additional overdoses and loss of life.

2019 Annual Report of the Kansas Poison Control Center at The University of Kansas Health System.

IntroductionThis is the 2019 Annual Report of the Kansas Poison Control Center (KSPCC) at The University of Kansas Health System. The KSPCC is one of 55 certified poison control centers in the United States and serves the state of Kansas 24-hours a day, 365 days a year with certified specialists in poison information and clinical and medical toxicologists. The KSPCC receives calls from the public, law enforcement, health care professionals, and public health agencies. All calls to the KSPCC are recorded electronically in the Toxicall® data management system and uploaded in near real-time to the National Poison Data System (NPDS) which is the data repository for all poison control centers in the United States.MethodsAll encounters reported to the KSPCC from January 1, 2019 through December 31, 2019 were analyzed. Data recorded for each exposure includes caller location, age, weight, gender, exposure substance, nature of exposure, route of exposure, interventions, medical outcome, disposition, and location of care. Encounters were classified as human exposure, animal exposure, confirmed non-exposure, or information call (no exposure reported).ResultsThe KSPCC logged 20,589 total encounters in 2019, including 19,406 human exposure cases. The KSPCC received calls from every county in Kansas. A slim majority of human exposure cases (50.5%, n = 9,790) were female. Approximately 61% (n = 11,876) of human exposures involved a child (defined as 19 years of age or less). Most encounters occurred at a residence (91.6%, n = 17,780) and most cases (64.9%, n = 12,599) originated from a residence. The majority of human exposures (85.5%, n = 16,589) were acute cases (exposures occurring over 8 hours or less). Ingestion was the most common route of exposure documented (85.3%, n = 16,548). The most commonly reported substance in pediatric (children ≤ 5) encounters was cosmetics/personal care products (n = 959) followed closely by household cleaning products (n = 943). For adult encounters, analgesics (n = 1,296) and sedative/hypnotics/antipsychotics (n = 1,084) were the most frequently involved substances. Unintentional exposures were the most common reason for exposures (75.4%, n = 14,634). Most encounters (65.9%, n = 12,780) were managed in a non-healthcare facility (i.e., a residence). Among human exposures, 14,591 involved exposures to pharmaceutical agents while 9,439 involved exposure to non-pharmaceuticals. Medical outcomes were 26.4% (n = 5,116) no effect, 18.8% (n = 3,652) minor effect, 9.3% (n = 1,813) moderate effect, and 3.1% (n = 603) major effects. There were 14 deaths in 2019 reported to the KSPCC. Cases from healthcare facilities and cases with moderate or major medical outcomes increased in 2019 compared to 2018. The number of deaths reported to the KSPCC increased in 2019 to 14 from 7 in 2018.ConclusionsThe results of the 2019 Kansas Poison Control Center’s annual report demonstrated that cases were received from the entire state of Kansas totaling over 19,400 human exposures per year. While pediatric exposures remained the most common encounter, there continued a trend of increasing number of cases from healthcare facilities and for cases with serious outcomes. The experience of the KSPCC is comparable to national data. This report supported the continued value of the KSPCC to both public and acute health care in the state of Kansas.

National Poison Data System (NPDS) review of intentional sodium nitrite ingestions 2009–2019

Ingesting sodium nitrite as a suicide method appears to be gaining popularity, spurred by online suicide blogs and an easily obtainable product. However, the exact nature of this trend has not been studied. We conducted an 11-year retrospective review of intentional sodium nitrite ingestions reported to the National Poison Data System from January 1, 2009-December 31, 2019. We included all cases coded as “nitrite or nitrate” in the initial request. We requested full case records for the initial cohort to confirm details. NPDS recorded 390 individual “nitrite or nitrate” exposures during the study period, and 42 met inclusion criteria. We received full case records for 35/42 patients, and 17 were included in the final cohort (N = 17). The mean age was 23.2 years old. Visible cyanosis was present in 13/17 patients with a mean oxygen saturation of 85%. Methylene blue was administered in 14/17 cases with 8/17 requiring advanced cardiac life support. The overall mortality rate was 41% (7/17). All patients presented in the final two years of the study period. Intentionally ingesting sodium nitrite represents a novel, growing trend and carries a high mortality rate among young adults. Abbreviations: AAPCC, American Association of Poison Control Center; ACLS, Advanced Cardiac Life Support; CPCS, California Poison Control System; NPDS, National Poison Data System; PCC, Poison Control Center; SPI, Specialist in Poison Information.

2018 Annual Report of the University of Kansas Health System Poison Control Center

This is the 2018 Annual Report of the Kansas Poison Control Center at The University of Kansas Health System (KSPCC). The KSPCC serves the state of Kansas 24-hours per day, 365 days a year with certified specialists in poison information and clinical and medical toxicologists. All encounters reported to the KSPCC from January 1, 2018 through December 31, 2018 were analyzed. Data recorded for each exposure included caller location, age, weight, gender, exposure substance, nature of exposure, route of exposure, interventions, medical outcome, disposition, and location of care. There were 21,072 total encounters, including 20,031 human exposure cases. Calls were received from every county and hospital in Kansas. Most of the exposures involved females (51.5%, n = 10,320) and a child less than 19 year of age (64%, n = 12,865). Medical outcomes were 24.5% (n = 4,912) no effect, 17.7% (n = 3,542) minor effect, 9.1% (n = 1,830) moderate effect, and 2.4% (n = 476) major effect. Seven deaths were reported in 2018. The number of exposure calls from healthcare facilities and severity of medical outcomes increased in 2018 compared to 2017. The 2018 KSPCC annual report demonstrated that the center receives calls from the entire state of Kansas totaling over 20,000 human exposures. While pediatric exposures remain the most common encounter, a trend continued of an increasing number of calls from healthcare facilities and for cases with serious outcomes. This report supported the continued value of the KSPCC to both public and acute health care in the state of Kansas.

Poison-related visits in a pediatric emergency department: A retrospective analysis of patients who bypass poison control centers

IntroductionPoison control centers (PCC) are an effective means to prevent unnecessary emergency department (ED) visits associated with poisoning exposures. However, not all patients with poison exposures utilize the PCC. The purpose of this study was to identify unintentional pediatric poisoning exposures presenting to a large US children's hospital that could have been managed onsite (i.e., at home) if consultation with a PCC had occurred prior to the ED visit. MethodsUsing ED encounters from a tertiary children's hospital, unintentional pharmaceutical, chemical, or fume exposures occurring between October 1, 2014 and September 30, 2015 were identified from ICD-9-CM billing codes. Two specialists in poison information reviewed the medical records of the identified patients who had no contact with the PCC and determined whether these encounters were preventable through PCC triage. Descriptive statistics examined the differences between the encounters. Data were analyzed in R v3.2.4 (Vienna, Austria) and SAS v9.4 (SAS Institute, Cary, NC). ResultsIn the total study population (n = 231), 98 (42.4%) were PCC triaged and 133 (57.6%) were caregiver self-referred to the ED. For those who self-referred, 62 (46.6%) patients would have been recommended to be managed onsite instead of presenting at the ED for medical care. Analgesics and household cleaning products were the most common pharmaceutical and chemical exposures, respectively. ConclusionsNearly half of ED visits for pediatric patients with unintentional poisoning exposures could have been avoided by contacting a PCC. Educational and self-efficacy-based interventions are needed to expand the public's use of PCC services.

2017 Annual Report of the University of Kansas Health System Poison Control Center

This is the 2017 Annual Report of the University of Kansas Health System Poison Control Center (PCC). The PCC is one of 55 certified poison control centers in the United States and serves the state of Kansas 24-hours a day, 365 days a year. The PCC receives calls from the public, law enforcement, health care professionals, and public health agencies, which are answered by trained and certified specialists in poison information with the immediate availability of medical toxicology back up. All calls to the PCC are recorded electronically in the Toxicall® data management system and uploaded in near real-time to the National Poison Data System (NPDS), which is the data repository for all poison control centers in the United States. All encounters reported to the PCC from January 1, 2017 to December 31, 2017 were analyzed. Data recorded for each exposure included caller location, age, weight, gender, substance exposed to, nature of exposure, route of exposure, interventions, medical outcome, disposition and location of care. Encounters were classified further as human exposure, animal exposure, confirmed non-exposure, or information call (no exposure reported). The PCC logged 21,431 total encounters in 2017, including 20,278 human exposure cases. Cases came from every county in Kansas. Most of the human exposure cases (51.4%, n = 10,430) were female. Approximately 66% (n = 13,418) of human exposures involved a child (defined as age less than 20 years). Most encounters occurred at a residence (94.0%, n = 19,018) and most calls (69.5%, n = 14,090) originated from a residence. Almost all human exposures (n = 19,823) were acute cases (exposures occurring over eight hours or less). Ingestion was the most common route of exposure documented (80.5%, n = 17,466). The most common reported substance in pediatric encounters was cosmetics/personal care products (n = 1,255), followed by household cleaning products (n = 1,251). For adult encounters, analgesics (n = 1,160) and sedatives/hypnotics/antipsychotics (n = 1,127) were the most frequently involved substances. Unintentional exposures were the most common reason for exposures (78.6%, n = 15,947). Most encounters (69.4%, n = 14,073) were managed in a non-health care facility (i.e., a residence). Among human exposures, 14,940 involved exposures to pharmaceutical agents, while 9,896 involved exposure to non-pharmaceuticals. Medical outcomes were 28% (n = 5,741) no effect, 18% (n = 3,693) minor effect, 9% (n = 1,739) moderate effect, and 2% (n = 431) major effect. There were 16 deaths in 2017 reported to the PCC. Number of exposures, calls from health care facilities, cases with moderate or major medical outcomes, and deaths increased in 2017 compared to 2016, despite a decrease in total exposures. The results of the 2017 University of Kansas Health System Poison Control annual report demonstrated that the center continues to receive calls from the entire state of Kansas, totaling over 20,000 human exposures per year. While pediatric exposures remain the most common, a trend of increasing number of calls remains from health care facilities and for cases with serious outcomes. The 2017 PCC data reflected current national trends. This report demonstrated the continued importance of the PCC to both the public and health care providers in the state of Kansas.

Considering toxicology: Specialists in poison information.

Toxicology is an interesting and specialized branch of medicine. This article examines the parallels between nursing and working as a specialist in poison information, offering a different career path for eligible nurses.

An epidemiologic and clinical description of e-cigarette toxicity

Introduction: E-cigarettes are battery-powered electronic nicotine delivery systems that simulate smoking by vaporizing nicotine-containing solutions. Systematic published data on e-liquid toxicity and exposures are limited to case reports and retrospective studies. Prospectively-collected data on the type of exposure, symptomatology, duration of symptoms, and concentration/flavor of e-fluids has not been published.Methods: This was a prospective observational study over a 42-month period (07/01/2014–12/31/2017). For all calls to a single poison center that involved e-cigarette devices or refill fluid, a data collection instrument was filled out by the specialist in poison information (SPI).Results: Two hundred sixty-five total cases were identified, including 193 children and 72 adults. The majority of both pediatric (72%; 139/193) and adult (61%; n = 44/72) exposures involved e-liquid refill containers or fluid. Fifty-six percent (n = 108/193) of pediatric exposures involved ingestion of refill liquid. Though children who ingested e-liquid received only a small amount, initial symptoms were evident in 32% (n = 35/108) of cases. Children who did not ingest or inhale the products were less likely to develop toxicity. Only 2 children who were asymptomatic on initial call became symptomatic on follow-up. Most patients symptoms resolved within 4 hours. Seventy-one specific products/brands were identified with nicotine concentrations ranging from 0 mg/mL to 60 mg/mL with one product containing 3000 mg in a single bottle. A variety of flavors were identified, including several with names that may be attractive to toddlers or adolescents.Discussion: E-cig exposures tend to produce irritant effects from topical exposures and nicotine toxicity from ingestions, as well as some dermal and “sucking” toddler exposures.Conclusion: Exposure to e-cig fluid or device frequently causes mild symptoms and rarely may produce systemic nicotine toxicity.

Physostigmine is superior to non-antidote therapy in the management of antimuscarinic delirium: a prospective study from a regional poison center

Context: Poison centers (PCs) frequently manage patients with antimuscarinic delirium. However, controversy surrounds the antidotal use of physostigmine for its treatment. The aim of this study was to prospectively investigate physostigmine versus non-antidote therapy for the management of antimuscarinic delirium in a single regional PC.Methods: This was a prospective observational analysis of patients diagnosed with antimuscarinic delirium and treated in consultation with a regional PC. Certified Specialists in Poison Information (CSPIs) use a clinical guideline to recommend the use of physostigmine. Using a previously derived altered mental status score, we quantified the rate of delirium improvement with physostigmine compared to non-antidote therapy two hours after initial patient identification. We also recorded adverse events (defined a priori as bradycardia, vomiting, seizures) and resource utilization (intubation and physical restraint).Results: We identified 245 patients and included 154 in the analysis. The most common exposure classes were antihistamines (68%), analgesics (19%), and antipsychotics (19%). CSPIs recommended physostigmine in 81% (125) of cases and the treatment team administered it in 37% (57) of these. We observed delirium control in 79% of patients who received physostigmine versus 36% of those who did not. The odds of delirium control were six times greater for patients receiving physostigmine than for patients treated with non-antidote therapy (OR 6.6). Adverse events were rare and did not differ significantly between the groups. Physostigmine was not associated with changes in the incidence of intubation or restraint.Conclusions: This study provides further evidence of both the safety and efficacy of physostigmine in the treatment of antimuscarinic delirium.

“Medibles”: Dangerous Treats

The Oregon Poison Center (OPC) received 3 calls in one shift regarding toddlers who had altered mental status. A 3-year-old was described as having “abnormal shaking movements.” Another toddler received intravenous fluids for hypotension, and the last child was intubated for multiple apneic spells in the emergency department. All their symptoms resolved overnight, and they were discharged the next day. Charisse Pizarro-Osilla is a Certified Specialist in Poison Information and Lead Charge RN Coordinator, Oregon Health & Science University, Oregon Poison Center, Portland, OR.

Tele-health: bridging the gap between the need for rapid toxicology consultation and shortage in poison control centers - a unique experience in Dammam poison control center

The development of poisons control centers (PCCs) has in general complied with the actual needs and conditions in the society. A single MOH toll-free telephone number (937) for all health services enables rapid transfer of the caller to a specialist in poison information and toxicology anywhere in the Saudi Kingdom at any time, day or night. A board-certified, qualified toxicologist can be reached within a few moments. This remarkable system is maintained by the voluntary cooperation of the 45 technical members of the Regional Dammam Poison Control Center (DPCC) since nearly three years, being the only PCC in the Kingdom offering this service till date.Objectives: The objective of the current study is to empathize and promote services delivered by PCCs as poison control, chemical safety, prevention and treatment of toxicities within the Saudi Kingdom through the single MOH toll-free telephone number (937), being the only Saudi PCC responding to this service in toxicology. It promotes toxicovigilance in the hope of decreasing the overall morbidity and minimizing mortality from poisoning.Methods: The calls received on the hotline telephone number of the DPCC directly conveying the calls from the free MOH line (937), were retrospectively studied and evaluated. Themes that emerged from the data obtained from telephone communication were statistically assessed.Results: The study showed that the Unintentional exposures (N= 4353, 85%) greatly surpassed other types of exposure. Most of the callers were Saudi (N=4198, 82%) from Eastern region (N= 1654, 32.3%). The toxicological calls (N: 2389, 87.6%) were nearly 7 folds of the non-toxicological calls (N: 337, 12.4%) in the third year of the study. The number of calls were more during the summer season.

A New Source for Nicotine Exposures in Pediatric Patients: Electronic Cigarettes

A mother brings her 18-month-old, 13-kg child to the emergency department and states that the child drank from a bottle of nicotine refill liquid for electronic cigarettes (e-cigarettes). The child vomited 3 times prior to arrival. The bottle has “18 mg” and “cherry-flavored e-liquid” on the label. Upon physical examination the child is awake but slightly drowsy, her pupils are 5 to 6 mm and reactive, her skin is slightly moist, and some drooling is noted. Vital signs are as follows: blood pressure, 76/52 mm Hg; heart rate, 138 beats per minute; respiratory rate, 36; oxygen saturation, 99%; and oral temperature, 37.1°C (98.7°F). Her lungs are clear. She has no tremors or fasciculations. Cindy Howard is Certified Specialist in Poison Information, Illinois Poison Center, Chicago, IL.

Prospective evaluation of pain, swelling, and disability from copperhead envenomation

Context: In light of the existing controversy regarding antivenin treatment for copperhead envenomation, a more detailed analysis of the disability from this species is needed. Objective: Our objective was to prospectively determine the duration of pain, swelling, and functional disability, i.e., residual venom effects, in patients with copperhead envenomation. Methods: Patients with venomous snakebite reported to the North Texas Poison Center between April 2009 and November 2011 were assessed. Patients with confirmed envenomations were contacted by a specialist in poison information. Day zero was the day of the bite and verbal phone consent for study enrollment was obtained at that time. The patient (or their guardian) was contacted by phone daily thereafter, and asked to rate their pain, edema/swelling, and disability using the modified DASH and LEFS scales. Patients were followed to resolution of all symptoms or return to baseline. Results: About 104 cases of venomous snakebite were followed; of which 17 were excluded due to being a dry bites (5) or for having insufficient data during follow-up (11) or due to coagulopathy (1). Overall, residual venom effects from copperhead bites for most patients last between 7 and 13 days. Median time to complete pain resolution was 7 days (mean = 10.7 days). Median length of time to resolution of swelling was 10 days (mean = 13 days) and median length of time to resolution of functional disability was 9 days (mean = 12.2 days). Discussion: Residual venom effects from copperhead envenomation in this study had a slightly shorter duration than some other studies. Data are skewed due to outliers where residual venom effects lasted for up to 89 days. Initial reoccurrence of some symptoms may be seen. Antivenom (AV) is currently being used for a large percentage of patients with copperhead envenomation. Finally, no differences in duration of venom effects were seen based on age or location of bite. Conclusion: Our study suggests that residual venom effects from copperhead species persist for between 10 and 13 days but may persist for months. Future studies are necessary to identify risk factors for severe/prolonged injury and to define the benefit of AV in patients with copperhead envenomation.

Career Planning in Public Health

Career Planning in Public Health

Four-hour acetaminophen concentration estimation after ingested dose based on pharmacokinetic models

Introduction. The United Kingdom has recently changed the indications for N-acetylcysteine treatment for acetaminophen intoxication. Any ingestion over 75 mg/kg is now referred to the hospital. A model based on pharmacokinetic parameters was developed to predict 4-h acetaminophen concentration for this and other ingested doses. Methodology. EMBASE and Medline were searched to obtain values for volume of distribution, absorption, and elimination constants and bioavailability for acetaminophen. Four-hour concentrations were calculated for ingestion doses currently recommended for hospital referral in different countries. Calculated plasma concentrations at 4 h for several doses were plotted against the Rumack-Matthew and the United Kingdom treatment lines. Results. Six articles were used for the calculations (4 adult and 2 pediatric). In order to achieve a 4-h acetaminophen concentration of 100 mg/L, doses (mg/kg ± 99.9CI) of 180.5 ± 43.2 for adults and 396.1 ± 115.5 for children were calculated. Discussion. A dose of 75 mg/kg would likely yield a 4-h acetaminophen concentrations well below 100 mg/L. Medical toxicologists and poison information specialists are left without evidence-based guidance for which patients or which ingestion history would now warrant referral to hospital for acetaminophen concentration measurement. Larger toxicokinetic studies in acetaminophen overdose are needed to define ingestion dose for referral to hospital.

Use of electronic learning modules for teaching pharmacy and nursing staff: How to locate and utilize drug information sources in a poison control center

ObjectiveThe primary purpose of this study was to help pharmacist and nursing specialists in poison information (SPIs) recognize the variety of electronic references available that could supplement Micromedex® to aid them with their calls at the poison control center (PCC). A secondary objective was to ascertain whether the training modules were an effective way to educate SPIs about electronic resources and how to use them effectively. MethodsSelf-paced electronic training was presented in five modules: eFacts, Lexi-comp, AccessMedicine/AccessPharmacy/STAT!Ref, Medline Part 1, and Medline Part 2. After reviewing the objectives, the SPI was directed to a pre-test designed to establish current understanding of the material in that module. They then progressed through a slide show, designed to give information about the resource and application in finding information related to poisonings and toxicity. A post-test was administered to evaluate the knowledge gained and the application of that knowledge in answering typical questions from callers. ResultsFourteen of 20 employees took the assessment: eight pharmacists, two nurses, one physician's assistant, and three students. Post-test scores were increased for all modules except in Module 3: Access Medicine/Access Pharmacy/STAT!Ref, with the highest increase in scores occurring for the Medline modules. Feedback was overall positive, and all employees said they had learned something that they did not know before taking the assessment. ConclusionsThis training program helped SPIs to recognize electronic references that could aid in finding information relating to calls at the PCC, and it appeared to be an effective way to educate SPIs about these electronic resources.

Practice or Perish: Why Bedside Toxicology is Essential to the Survival of Our Specialty

One of the medical toxicologists in our group was recently asked a shocking question. She was providing recommendations via telephone to a rather upset and flustered emergency physician, when the caller interrupted her by asking, “Excuse me, are you even a clinician?” Working on a toxicology service that admits and consults on more than 1,200 patients per year, my colleague was understandably taken aback. Hearing the story later, I was dismayed but not surprised. Based on the current practice of many toxicologists, how can we fault the emergency physician for asking such a question? Medical toxicology has become a specialty in which the telephone has largely replaced the stethoscope as the primary tool of our trade. This is in no way meant to diminish the importance of poison control centers. Not only was the establishment of poison centers instrumental in the development of medical toxicology as a subspecialty [1], there is no doubt as to the public health benefit and system-wide cost savings engendered by poison centers [2–7]. My concern is the role played by toxicologists in our healthcare system. Presumably, fellowship training in medical toxicology allows us to make clinical recommendations and advise caregivers at a level beyond that of the emergency physician and poison information specialist. If this is true, how many patients does the medical toxicologist have to treat at the bedside to ensure the validity of our advice? What happens when the emergency physician on the other end of the telephone has laid hands on more poisoned patients in the preceding week than the toxicologist has in the preceding year? If we do not examine patients, treat them at bedside, and learn from our experience, what is it that distinguishes us from Poisindex™ or a poison information specialist?