Unintentional Pediatric Poisoning Exposures in an Emergency Department: A Comparison of Poison Control Center Referrals and Caregiver Self-Referred Visits.

OBJECTIVES: The purpose of this study is to describe the demographics and clinical characteristics of patients referred to a pediatric emergency department (ED) for unintentional poisoning exposures by a poison control center (PCC) compared with patients/caregivers who self-refer. METHODS: The electronic data warehouse at a pediatric hospital was queried from October 1, 2014, to September 30, 2015, for unintentional poisoning-related ED visits and subsequent inpatient admissions. Eligible patients aged 18 years and younger were identified by International Classification of Diseases, Ninth Revision, Clinical Modification codes for pharmaceuticals, non-pharmaceuticalchemicals, fumes/vapors, foreign bodies, adverse food reactions, food poisoning, and bites/stings. Referral classification (PCC referral vs self-refer) was determined by PCC and hospital medical records.Descriptive statistics were used to characterize the patient demographics and ED visits by referral classification and age group. Simple and multiple logistic regression models examined the individual and combined impact of demographic and clinical characteristics on self-referral. RESULTS: Of the 705 patients identified, 84.4% presented as caregiver/self-referred compared with PCC-referred. As compared with those who self-referred, a higher percentage of patients who contacted the PCC before ED presentation were white (93.9% [89.4-98.2%] vs 83.8% [80.7-86.7%]) and had commercial insurance (62.7% [51.5-69.5%] vs 53.0% [48.9-57.0%]). Pharmaceutical (71.9%) and chemical (14.0%) exposures were the most common exposure types for PCC-referred patients whereas foreign bodies (54.3%) were the most common for self-referred patients. The largest predictors of self-referral were age, insurance, and exposure type. CONCLUSIONS: Among patients presenting at 1 pediatric ED, disparities with PCC utilization exist among age groups, racial identification, and poison exposure type. Educational outreach interventions are needed to ensure optimal use of the PCC services by patients, caregivers, and health care professionals.

Enabling health information exchange at a US Poison Control Center.

OBJECTIVE: The objective of this project was to enable poison control center (PCC) participation in standards-based health information exchange (HIE). Previously, PCC participation was not possible due to software noncompliance with HIE standards, lack of informatics infrastructure, and the need to integrate HIE processes into workflow. MATERIALS AND METHODS: We adapted the Health Level Seven Consolidated Clinical Document Architecture (C-CDA) consultation note for the PCC use case. We used rapid prototyping to determine requirements for an HIE dashboard for use by PCCs and developed software called SNOWHITE that enables poison center HIE in tandem with a poisoning information system. RESULTS: We successfully implemented the process and software at the PCC and began sending outbound C-CDAs from the Utah PCC on February 15, 2017; we began receiving inbound C-CDAs on October 30, 2018. DISCUSSION: With the creation of SNOWHITE and initiation of an HIE process for sending outgoing C-CDA consultation notes from the Utah Poison Control Center, we accomplished the first participation of PCCs in standards-based HIE in the US. We faced several challenges that are also likely to be present at PCCs in other states, including the lack of a robust set of patient identifiers to support automated patient identity matching, challenges in emergency department computerized workflow integration, and the need to build HIE software for PCCs. CONCLUSION: As a multi-disciplinary, multi-organizational team, we successfully developed both a process and the informatics tools necessary to enable PCC participation in standards-based HIE and implemented the process at the Utah PCC.

Legal aspects of information sharing and communication by poison centers in the United States.

To keep pace with changing technology and to provide better treatment to the public, U.S. poison control centers have increasingly implemented new ways of communicating with healthcare providers and with patients, including electronic transfer of patient information. Innovation in communication and information sharing raises concerns over patient privacy and compliance with applicable laws. This narrative review analyzes both typical activities and emerging innovations of PCCs in relation to U.S. law and regulation regarding privacy, specifically the Health Insurance Portability and Accountability Act, the Substance Abuse and Mental Health Treatment Act, and the Federal Trade Commission Act. PCCs that are "covered entities" under HIPAA may exchange patient health information with other providers by telephone for purposes of treatment, and certainly during the emergency management of poisonings. SAMHSA regulations, however, limit information that can be shared outside of emergencies without patient consent. The FTC Act prohibits unfair or deceptive trade practices which may in some circumstances involve privacy violations. Text message exchanges between PCCs and patients present particularly difficult privacy challenges under these laws.

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

INTRODUCTION: Poison 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. METHODS: Using 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). RESULTS: In 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. CONCLUSIONS: Nearly 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.

Study of Caregivers Regarding Pediatric Poisoning.

The overall objective was to characterize action by caregivers when a potential poison exposure occurs and identify barriers to poison control center (PCC) utilization. A prospective survey of caregivers of pediatric patients who presented to an emergency department for a potential poison exposure was completed by each study participant. A total of 371 surveys were completed between August 2016 and August 2017. The majority of patients were 3 years or younger. Caucasians were more likely to have heard of the PCC, had the toll-free number available, and had previously called compared with other races and ethnicities. Caregivers with some government insurance were more likely to think that PCCs report child poisoning calls to authorities. Education efforts of nationwide PCCs focus on awareness of the PCC as well as poison prevention strategies. Understanding barriers to utilization of PCC and populations who are more likely to underutilize the PCC can help direct education efforts.

Simple Workflow Changes Enable Effective Patient Identity Matching in Poison Control.

BACKGROUND: U.S. poison control centers pose a special case for patient identity matching because they collect only minimal patient identifying information. METHODS: In early 2017, the Utah Poison Control Center (Utah PCC) initiated participation in regional health information exchange by sending Health Level Seven Consolidated Clinical Document Architecture (C-CDA) documents to the Utah Health Information Network and Intermountain Healthcare. To increase the documentation of patient identifiers by the Utah PCC, we (1) adapted documentation practices to enable more complete and consistent documentation, and (2) implemented staff training to improve collection of identifiers. RESULTS: Compared with the same time period in 2016, the Utah PCC showed an increase of 27% (p < 0.001) in collection of birth date for cases referred to a health care facility, while improvements in the collection of other identifiers ranged from 0 to 8%. Automated patient identity matching was successful for 77% (100 of 130) of the C-CDAs. CONCLUSION: Historical processes and procedures for matching patient identities require adaptation or added functionality to adequately support the PCC use case.

Acute pneumonitis associated with nickel carbonyl exposure in the workplace.

BACKGROUND: We describe the clinical course of one industrial technician occupationally exposed to nickel carbonyl (NiC). CASE REPORT: A 50-year-old male industrial technician presented with complaints of nausea, myalgia, and cough to a local clinic after suspected occupational exposure to nickel carbonyl. He has no history of lung disease or smoking. His initial urine nickel concentration was 692 ug/L. He had infiltrates on the initial chest X-ray (CXR) and an oxygen saturation (O2) of 97% on room air. The patient was started on disulfiram 1 g by mouth (PO), 500 mg six hours after the first dose, then 250 mg twice daily for five days with prednisone 60 mg by mouth for five days. He presented 48 hours later with worsening respiratory symptoms. His O2 saturation decreased to 85% despite two days of oral steroids, and he was admitted to a hospital. He received prednisone 60 mg/day PO, 4 L nasal O2, and disulfiram 500 mg twice daily. He was discharged on day 7 post-exposure with disulfiram and prednisone. Case discussions: NiC is a severe respiratory irritant. Disulfiram was used off-label and was based on an established company protocol. CONCLUSIONS: Inhalation exposure to NiC resulted in a delayed respiratory dysfunction which responded to disulfiram treatment.

The value of a poison control center in preventing unnecessary ED visits and hospital charges: A multi-year analysis.

OBJECTIVE: The purpose of this study is to determine the economic value of the Utah Poison Control Center (UPCC) by examining its contribution to the reduction of unnecessary emergency department (ED) visits and associated charges across multiple years. METHODS: A multi-year (2009-2014) analysis of cross-sectional data was performed. Callers were asked what they would do for a poison emergency if the UPCC was not available. Healthcare charges for ED visits averted were calculated according to insurance status using charges obtained from a statewide database. RESULTS: Of the 10,656 survey attempts, 5018 were completed. Over 30,000 cases were managed on-site each year. Using the proportion of callers who noted they would call 911, visit an ED, or call a physician's office, between 20.0 and 24.2 thousand ED visits were potentially prevented each year of the survey. Between $16.6 and $24.4 million dollars in unnecessary healthcare charges were potentially averted annually. CONCLUSIONS: Compared to the cost of operation, the service UPCC provides demonstrates economic value by reducing ED visits and associated charges. As the majority of patients have private insurance, the largest benefit falls to private payers.

Software Prototyping: A Case Report of Refining User Requirements for a Health Information Exchange Dashboard.

BACKGROUND: Health information exchange (HIE) between Poison Control Centers (PCCs) and Emergency Departments (EDs) could improve care of poisoned patients. However, PCC information systems are not designed to facilitate HIE with EDs; therefore, we are developing specialized software to support HIE within the normal workflow of the PCC using user-centered design and rapid prototyping. OBJECTIVE: To describe the design of an HIE dashboard and the refinement of user requirements through rapid prototyping. METHODS: Using previously elicited user requirements, we designed low-fidelity sketches of designs on paper with iterative refinement. Next, we designed an interactive high-fidelity prototype and conducted scenario-based usability tests with end users. Users were asked to think aloud while accomplishing tasks related to a case vignette. After testing, the users provided feedback and evaluated the prototype using the System Usability Scale (SUS). RESULTS: Survey results from three users provided useful feedback that was then incorporated into the design. After achieving a stable design, we used the prototype itself as the specification for development of the actual software. Benefits of prototyping included having 1) subject-matter experts heavily involved with the design; 2) flexibility to make rapid changes, 3) the ability to minimize software development efforts early in the design stage; 4) rapid finalization of requirements; 5) early visualization of designs; 6) and a powerful vehicle for communication of the design to the programmers. Challenges included 1) time and effort to develop the prototypes and case scenarios; 2) no simulation of system performance; 3) not having all proposed functionality available in the final product; and 4) missing needed data elements in the PCC information system.

A Retrospective Study of Clinical Effects of Powdered Caffeine Exposures Reported to Three US Poison Control Centers.

INTRODUCTION: Anhydrous caffeine, often sold on the Internet as a powdered caffeine product, is sold as "pure caffeine" to be used as an additive to beverages and has also been used as an ingredient in energy supplement products. METHODS: This is a retrospective multiple-poison center chart review of calls regarding powdered caffeine to poison centers covering Oregon, Alaska, Guam, Washington, and Utah between January 1, 2013 and June 30, 2015. RESULTS: There were 40 calls to three poison centers over 30 months for powdered caffeine exposure. The majority of patients were over age 19 (52.5 %; 21/40) and male (70 %; 28/40). Sixty percent (24/40) of the patients were symptomatic but only 10 % (4/40) required admission; 52.5 % (21/40) of the patient calls were for inadvertent overdose of powdered caffeine; one patient overdosed in a self-harm attempt. DISCUSSION: Powdered caffeine calls to three poison centers during a 30-month study period were rare, and severe caffeine toxicity due to exposure was found in few patients. The majority of symptoms were reported after an inadvertent powdered caffeine overdose. CONCLUSIONS: An analysis of calls to three poison centers for powdered caffeine found that exposures were uncommon, but did result in toxicity, and highlighted that the lack of clear dosing instructions on product packaging may place patients at risk of inadvertent overdose.

Data standards to support health information exchange between poison control centers and emergency departments.

OBJECTIVE: Poison control centers (PCCs) routinely collaborate with emergency departments (EDs) to provide care for poison-exposed patients. During this process, a significant amount of information is exchanged between EDs and PCCs via telephone, leading to important inefficiencies and safety vulnerabilities. In the present work, we identified and assessed a set of data standards to enable a standards-based health information exchange process between EDs and PCCs. MATERIALS AND METHODS: Based on a reference model for PCC-ED health information exchange, we (1) mapped PCC-ED information exchange events to clinical documents specified in the Health Level Seven (HL7) Consolidated Clinical Document Architecture (C-CDA) Standard, and (2) mapped information types routinely exchanged in PCC-ED telephone conversations to C-CDA sections. RESULTS: Four C-CDA document types were necessary to support the PCC-ED information exchange process: History & Physical Note, Consultation Note, Progress Note, and Discharge Summary. Information types that are commonly exchanged between PCCs and EDs can be reasonably well represented within these C-CDA documents. CONCLUSIONS: A standards-based health information exchange process between PCCs and EDs appears to be feasible given a set of clinical data standards that are required for EHR certification in the USA, although the proposed approach still needs to be validated in actual system implementations. Such a process has the potential to improve the safety and efficiency of PCC-ED communication, ultimately resulting in improved patient care outcomes.

Information Requirements for Health Information Exchange Supported Communication between Emergency Departments and Poison Control Centers.

We analyzed audio recordings of telephone calls between emergency departments (EDs) and poison control centers (PCCs) in order to describe the information requirements for health information exchange. Analysis included a random sample of 120 poison exposure cases involving ED-PCC communication that occurred during 2009. We identified 52 information types characterized as patient or provider information, exposure information, ED assessment and treatment/ management, or PCC consultation. These information types constitute a focused subset of information that should be shared in the context of emergency treatment for poison exposure. Up to 60% of the information types identified in the analysis of call recordings can be represented using existing clinical terminology. In order to accomplish standards-based health information exchange between EDs and PCCs using data coded according to a standard clinical terminology system, it is necessary to define appropriate terms, information models and value sets.

Inefficiencies and vulnerabilities of telephone-based communication between U. S. poison control centers and emergency departments.

CONTEXT: Poison control centers (PCCs) and emergency departments (EDs) rely upon telephone communication to collaborate. PCCs and EDs each create electronic records for the same patient during the course of collaboration, but those electronic records are not shared. OBJECTIVE: The purpose of this study was to describe the current, telephone based process of PCC-ED communication as the basis for potential process improvement. MATERIALS AND METHODS: This study was conducted at one PCC and two tertiary care EDs. We developed workflow diagrams to depict clinician descriptions of the current process, descriptions obtained through interviews of key informants. We also analyzed transcripts of phone calls between emergency departments and the poison control center, corresponding to a random sample of 120 PCC cases occurring January 1-December 31, 2011. RESULTS: Collaboration between the ED and PCC takes place during multiple telephone calls, and the process is unsupported by shared documentation. The process occurs in three phases: notification, collaborative care, and ongoing consultation. In the ED, multiple care providers may communicate with the PCC, but only one ED care provider communicates with the poison control center specialist at a time. Handoffs occur for both ED and PCC. Collaborative care planning is common and most cases involve some type of request for information, whether vital signs, laboratory results, or verification that a treatment was administered. We found evidence of inefficiencies and safety vulnerabilities, including the inability of PCC specialists to reach ED care providers, telephone calls routed through multiple ED staff members in an attempt to reach the appropriate care provider, and exchange of clinical information with non-clinical staff. In 55% of cases, the patient was discharged prior to any synchronous telephone communication between the ED care provider and a PCC specialist. Ambiguous communication of information was observed in 22% of cases. In 12% of cases, a PCC specialist was unable to obtain requested information from the ED. DISCUSSION AND CONCLUSION: Inefficiencies and vulnerabilities occur in telephone-based PCC-ED communication. Prudence begs consideration of alternative processes and models of ED-PCC communication and information sharing, including a process that supports collaboration with health information exchange.

Electronic information exchange between emergency departments and poison control centers: a Delphi study.

CONTEXT: The US emergency departments and poison control centers use telephone communication to exchange information about poison exposed patients. Electronically exchanged patient information could better support care for poisoned patients by improving information availability for decision making and by decreasing unnecessary emergency department telephone interruptions. As federal initiatives push to increase clinical health information exchange (HIE), it is essential to assess the readiness of US poison control centers. We conducted a nationwide Delphi study to determine consensus on legal, operational, and clinical considerations that are important for electronic information exchange between emergency departments and poison control centers. MATERIALS AND METHODS: A national panel of US experts (n = 71) in emergency medicine and poison control participated in a Delphi study, September-December 2010. Panelists rated statements describing concepts related to implementation, adoption, or potential outcomes of electronic information exchange between emergency departments and poison control centers. The statements reflected panelist responses to initial open-ended questions and literature-based concepts. RESULTS: A total of 71 panelists agreed to participate. The response rate for each round ranged from 0.73 to 0.77. Most (114/121) statements reached consensus. Seven statements failed to reach consensus. Panelists indicated that user involvement in the design of systems and tools is important. Workflow integration, safety, evidence of benefit, and outcomes are high-importance issues. DISCUSSION/CONCLUSIONS: Future research and development related to electronic information exchange should address high-importance issues: safety, patient outcomes, workflow integration, and evidence of benefit. It should also address key barriers: initial and ongoing costs associated with electronic information exchange, the absence of software and tools to facilitate exchange, and the need for training. Users should be involved in the design of an electronic information exchange process, and the process should support, not replace, verbal communication.

Exploring challenges to telehealth communication by specialists in poison information.

The use of the telephone for providing health care is growing. A significant amount of social meaning is derived from visual information, and the absence of visual stimuli provides unique barriers to communication and increases the risks for misunderstandings and distractions. Understanding challenges to telephone communication can provide insight into training opportunities for overcoming these difficulties and improving patient care. The purpose of this research was to explore through focus groups the challenges of phone communication perceived by specialists in poison information. General types of challenges to effective phone communication included developing new communication skills to compensate for lack of visual information, difficulty assessing caller understanding, difficulty managing caller misunderstandings, maintaining distinctive assessments for routine calls, and managing the multifaceted aspects of job stress. The desire for training to enhance telehealth and cultural competency skills was also mentioned, and these findings might provide guidance for the development of training opportunities for telehealth professionals.

Communication patterns for the most serious poison center calls.

CONTEXT. The communication demands faced by specialists in poison information (SPI) are unique in the health-care context. OBJECTIVES. (1) To describe SPI communication patterns for the highest risk poison exposure calls using cluster analysis, and (2) to describe variation in communication patterns or clusters. METHODS. A sample of 1 year of poison exposure calls to a regional poison control center with SPIs' perceived severity rating of major or moderate perceived was collected. Digital voice recordings were linked with medical records and were coded using the Roter Interaction Analysis System. Descriptive analyses were applied, and cluster-analytic techniques were used to assess variation in call communication and factors associated with that variation. RESULTS. Cases were described, and four communication styles were identified. The informational cluster represents calls with relatively high levels of SPI clinical information and caller questions. The Facilitative cluster represents calls with a pattern of relatively high SPI questions and caller information provision. The Planning cluster represents calls with relatively high levels of SPI relationship talk. The Emotional cluster represents calls with relatively high caller and SPI emotion. Further analyses revealed relationships between call characteristics, SPI identity, and cluster membership. CONCLUSION. This study provides a beginning step to understanding SPI communication behaviors. Our results suggest that SPIs are able to use a range of communication strategies that often involve not only information but also emotional responsiveness and rapport building. Findings also point to the opportunity for future communication training for SPIs to meet the needs of the heterogeneous caller population.

Tele-health: lessons and strategies from specialists in poison information.

OBJECTIVE: The use of the telephone for providing healthcare is growing. The aim of this exploratory study was to describe tele-health lessons and strategies as discussed by specialists who provide information and recommendations on poison control hotlines. METHODS: Three focus groups of 25 participants who work as specialists in poison information in poison control centers were conducted. Group discussions were analyzed using qualitative content analysis. RESULTS: Themes that emerged from the data on strategies for telephone communication include: taking control of the call, developing a therapeutic relationship, tailoring communication to fit each caller, preventing information overload, confirming caller understanding, and hands-on training for the development of telephone communication skills. CONCLUSION: Specialists in poison information identified challenges specific to communicating with patients over the telephone and reported several types of strategies they used to manage them. PRACTICE IMPLICATIONS: Telephone communication training may be needed to assist health care providers in improving their communication skills.

Pulmonary toxicity following exposure to waterproofing grout sealer.

INTRODUCTION: We report a large number of cases of pulmonary toxicity from 6 regional poison control centers associated with the use of a waterproofing-grout sealer. The identification of this illness occurred by means of the poison control center (PCC) national automated toxicosurveillance. MATERIALS AND METHODS: This is a retrospective case review of all cases of pulmonary toxicity following exposure to a waterproofing grout sealer from 6 regional PCCs including Michigan, Kentucky, Utah, Maine, Arizona, and Nebraska. The study period extended from June 1, 2005 to December 1, 2005. RESULTS: The vast majority of patients used the product at home (80%). Over half the patients presented within 3 hours of exposure. The most common presenting symptoms were shortness of breath (63%), cough (60%), and chest pain (44%). Wheezing (33%) and rales (23%) were the most common signs of clinical toxicity. One patient required endotracheal intubation. Thirty-seven percent of patients had signs of acute pneumonitis on initial chest x-ray. The mean presenting oxygen saturation was 89.5%. The most common treatment measures used were supplemental oxygen, bronchodilator therapy, oral steroids, and antibiotics. Over half of the study group required hospital admission. CONCLUSION: The majority of patients in this study were adults using the product at home. Over one-third of patients had an abnormal x-ray upon presentation. Over half of the study group required hospital admission following exposure to this product. Medical professionals should be aware of the potential for pulmonary toxicity due to waterproofing aerosols.