Poison Fighters

Control Centers Save Lives, Money 

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Public Health Feature – September 2012 

Tex Med. 2012;108(9):27-32.

By Crystal Conde 
Associate Editor 

Fifteenth-century scientist Paracelsus said: "All things are poison, and nothing is without poison; only the dose permits something not to be poisonous." This famous quote is many toxicologists' mantra and for good reason.

According to the Centers for Disease Control and Prevention (CDC), unintentional poisoning death rates have risen steadily since 1992. In 2009, 31,758 (76 percent) of the 41,592 poisoning deaths in the United States were unintentional, and 3,349 (8 percent) were of undetermined intent.

"Prescription Painkiller Overdoses in the U.S.," published in Vital Signs in 2011, indicates that in 2009, drugs caused 28,754 (91 percent) of all unintentional poisoning deaths. Prescription painkillers such as methadone, hydrocodone, and oxycodone were most commonly involved, followed by cocaine and heroin, the report says.

Unintentional poisoning affects U.S. children, as well. Fortunately, Texas residents and physicians have free access to a network of poison control centers that saves lives and money.

By calling (800) 222-1222, anyone in Texas can reach physicians, nurses, paramedics, and pharmacists specially trained in toxicology. Known as specialists in poison information (SPIs), they are supervised by a board-certified medical toxicologist and respond to calls from emergency departments, emergency medical service personnel, physicians, law enforcement officers, the public, and others with free consultation, case management, and follow-up.

Scot Morris, MD, a Brownwood pediatrician and member of the TMA Committee on Child and Adolescent Health, says he contacts poison control four or five times a year and always receives "prompt expert advice."

In February, he called his local poison center after a young patient ingested an entire bottle of chewable Tylenol.

"Poison control was instrumental in managing this case and probably helped my patient avoid a liver transplant," he said.

A 2009 article in American Journal of Preventive Medicine notes between 2004 and 2005, an estimated 71,000 children visited emergency departments each year because of medication poisonings – excluding abuse and recreational drug use. More than 80 percent of cases occurred because an unsupervised child found and consumed medications. The report also points out that among children, emergency department visits for medication poisonings – excluding misuse or abuse – are twice as common as poisonings from other household products such as cleaning solutions and personal care products.

When a child has ingested a drug or a potentially poisonous household product, Dr. Morris explains, a poison center toxicologist can determine whether a dangerous, life-threatening exposure has occurred.

"Part of routine checkups includes teaching parents how to contact poison control. I often see or talk to parents who have had a child ingest something that turned out to be benign. A call to poison control often prevents children from having to go to the emergency room and saves money," Dr. Morris said.

He adds the centers serve a larger public health role. Poison control centers provide an important surveillance service. They're often the first to identify illegal or new substances commonly being abused, such as bath salts or synthetic marijuana.

Sharilyn Stanley, MD, poison program coordinator of the Commission on State Emergency Communications (CSEC), hopes experiences like those of Dr. Morris will increase awareness of and use of the Texas Poison Control Network's services and resources. CSEC administers the network, including funding and overseeing the state's six regional poison control centers.

"Texas' poison control centers provide valuable resources. Physician consultation with the centers' board-certified toxicologists is underutilized, and we want to change that," she said.  

Centers Have Value   

The Texas Poison Control Network has six centers that are affiliated with medical institutions: 

  • Central Texas Regional Poison Control Center, Scott & White Memorial Hospital, Temple;
  • North Texas Regional Poison Control Center, Parkland Health & Hospital System and Dallas County Hospital District, Dallas;
  • Panhandle Regional Poison Control Center, Texas Tech University Health Sciences Center, Amarillo;
  • Southeast Texas Regional Poison Control Center, The University of Texas Medical Branch at Galveston;
  • South Texas Regional Poison Control Center, University of Texas Health Science Center at San Antonio; and
  • West Texas Regional Poison Control Center, University Medical Center and El Paso County Hospital District, El Paso. 

Miguel Fernández, MD, medical director of the South Texas Poison Center, calls the poison control centers "one of the best investments out there," adding that medical professionals provide treatment recommendations.

He recalls an incident in which a military hospital called his poison center when a young woman overdosed on methotrexate and wasn't breathing. Dr. Fernández consulted on the call and helped the physicians resuscitate her.

"I was able to relay my expert medical recommendations to the doctors in real time, and they brought her back," he said.

Poison control centers can also send a poison control specialist to speak to physicians, public health officials, paramedics, nurses, and other health care professionals. Contact your local poison control educator to schedule a poison education program.

Dr. Stanley says poison control centers are particularly valuable for physicians and patients in the state's rural and medically underserved regions because physicians "can always call the poison control centers 24 hours a day, seven days a week, year-round to get the expertise of a board-certified medical toxicologist. The centers' health professionals can direct physicians to nearby facilities for patient treatment and can recommend an alternative if a particular antidote is unavailable."

The centers also save money. Citing data from the American Association of Poison Control Centers (AAPCC), Dr. Stanley says on average, 70 percent of human exposure calls are treatable at home, avoiding far more costly hospital or doctor's office visits.

She says human exposure cases involve "the possibility of poisoning." For instance, human exposure could entail a child who ingested bleach or medication.

By keeping Texans out of emergency departments, ambulances, clinics, and physicians' offices, the West Texas Regional Poison Center in El Paso has saved the health care system $59 million since the center opened in 1995, according to its director, Leo Artalejo III, a doctor of pharmacy.

Dr. Stanley says in 2011, Texas' poison centers processed 386,971 calls, handled 175,866 human exposure cases, and followed up on 175,037 human exposure cases.

Poison control centers also reach out to their communities, taking steps to reduce the number of and severity of poison exposures. In addition to saving lives, AAPCC estimates poison control centers are three times as cost effective as child safety seats, bicycle helmets, and smoke detectors and are as cost effective as childhood immunizations.

A 2007 New Jersey study published in Journal of Toxicology and Environmental Health examined differences in length of hospital stay among poisoned patients who received remote assistance from a poison control center and those who did not. The study concluded that patients who received remote assistance from a poison control center stayed in the hospital three fewer days than those without poison control center assistance.

The report illustrates cost savings using 2002 New Jersey Department of Health and Senior Services statistics that indicate average charges for a day in the hospital for a poisoned patient were $6,000. Assuming assistance from the New Jersey Poison Information and Education System decreased the average hospital stay by just one day, the annual savings would total more than $10 million statewide.  


Pennywise, Pound Foolish 


Poison control centers receive state and federal funds. Like many other state-funded programs, Texas' centers took a hit to the budget for 2012-13. Dr. Stanley says none have had to close, but she describes the current operational status as "lean." For 2010-11, CSEC funding to support Texas Poison Control Network operations totaled $15.6 million. In contrast, poison control centers received $10.8 million for 2012-13.

Federal dollars make up about 20 percent of the network's budget. For fiscal year 2011, the centers received $2 million in federal funding. Dr. Stanley says the Health Resources and Services Administration (HRSA) hasn't yet awarded funds for fiscal year 2012 but has indicated funds will total about $2 million for the state's poison control centers.

In response to recommendations received during the 82nd legislative session and to adapt to lower levels of funding, Dr. Stanley says CSEC and the Texas Poison Control Network developed a plan to make poison control program operations more efficient.

Among the measures, poison control centers instituted network-wide staff scheduling, and a statewide health care facilities database is being developed to allow the centers to receive and respond to calls from anywhere in Texas. Instead of each center operating 24 hours a day, seven days a week, the centers schedule SPIs to match the volume of calls received over time and use a rollover phone system to manage calls.

"The service continues to be provided but at lower operating costs. Network scheduling is an effective way to manage staff across the centers and maximize their efficiency. Regional calls still primarily go to the regional poison control center where special expertise may exist.

During the 2011 legislative session, lawmakers introduced legislation to save money by transforming Texas' poison control infrastructure. House Bill 1015, filed by Rep. Linda Harper-Brown (R-Irving) to consolidate the regional poison control centers into one Texas Poison Control Center, did not make it out of the House Committee on Public Health.

In a letter opposing the bill, TMA wrote that "one center for the entire state simply cannot serve the entire state of Texas and provide the same type of cost savings to the patient and the state." The association added that "consolidating the Texas Poison Control Network centers into a single entity would have far more negative consequences than positive outcomes" and "would mean losing the toxicology knowledge and expertise 'multiplier effect.'"

Another compelling argument against consolidation: The centers could lose accreditation, which would eliminate crucial unmatched federal funding from HRSA. Dr. Stanley says the centers rely on the money to provide assurance of quality medical oversight.

AAPCC accredits poison control centers nationally and recommends that each center serve 5 million but no more than 10 million people. Texas is home to about 25 million people. If the state has only one poison control center, AAPCC would have grounds to consider de-accreditation of the entity.

"Loss of AAPCC accreditation would be disastrous for Texas' poison control system. It would be more difficult for the state to attract board-certified medical toxicologists to the centers and would place the centers' federal funding in jeopardy," Dr. Stanley said.

Medical institutions host Texas' six poison control centers and make significant in-kind contributions. CSEC provided an example of the added value host institutions lend to poison control centers its 2011 Report on the Texas Poison Control Network in response to the Sunset Advisory Commission.

"Without the North Texas Poison Center, Parkland Hospital and UT Southwestern Medical School could likely not maintain their Medical Toxicology Fellowship training program. This would be a tremendous loss to the State of Texas, as certified medical toxicologists are in short supply nationally and in Texas and are the only specialists who can assure rapid and proper management of a broad variety of human poisonings, venom exposure, and other toxic exposures," the agency wrote. The CSEC sunset report estimates the host institutions provide about $1.4 million worth of in-kind unreimbursed funds to the centers statewide.  

Centers Vital in Emergencies 

Dr. Artalejo says many physicians don't realize Texas' poison control centers also are important in emergency preparedness and response.

The centers work directly with local emergency response planning committees to support responders' use of the centers during emergencies.

When Hurricane Ike hit the state in 2008, employees at the Southeast Texas Regional Poison Control Center in Galveston had to evacuate. The center closed for 19 days.

Dr. Artalejo says during that time, the Texas Poison Control Network's rollover call system operated "seamlessly." The West Texas Regional Poison Control Center alone fielded 40 percent of calls coming from the Southeast Texas Regional Poison Control Center service region during the closure. Other centers throughout the state handled the remaining volume of calls.

"Any emergency communication system needs to have redundancy because no single place in Texas is immune from being shut down by a natural disaster or public health emergency. Consolidating the network into one location could be catastrophic for Texas in the midst of a natural disaster or public health emergency," Dr. Artalejo says.

In the aftermath of Hurricane Ike, health professionals, emergency medical technicians, and Texas residents most commonly called about carbon monoxide exposure from generator use in unventilated areas, prescription drug exposure by children, exposure to rat and mice poison, and food poisoning due to improper food storage, Dr. Artalejo says.

"The poison control centers were invaluable during Hurricane Ike. Many people who needed care didn't have access to hospitals or clinics. They were able to consult with a health professional by calling the toll-free number," Dr. Artalejo said.

Threatening the Network  


No one knows what the 2013 legislative session holds, but clearly Texas still faces budget challenges that could impact the poison control network. Dr. Stanley says lawmakers could pursue efforts to cut funding further, including consolidating the centers.

"CSEC is already at the tipping point of being able to fund six centers in Texas. There really isn't any fat in the system. If we experience more reductions, we could lose our highly qualified SPIs and the expertise of a robust regional network that serves the state," she said.

Dr. Fernández says additional funding reductions will stress the state's poison control system and could shift a hefty health care burden onto emergency departments.

"The centers are running as efficiently as they possibly can now. Additional cuts will threaten their survival," he said.

Dr. Stanley urges physicians to spread a unified message of support for poison control centers among their elected officials: "Texas' poison control centers are pivotal tools in the medical framework, and to defund them is only going to cost the state more money." Dr. Stanley also encourages her physician colleagues to take advantage of poison control expertise that's a simple phone call away: (800) 222-1222. 

Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email. 

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