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.

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.

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.

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.

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.

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.

An examination of adherence strategies and challenges in poison control communication.

INTRODUCTION: The principal objective of this study was to characterize how nurses and pharmacists at a poison control center (PCC) determine the likelihood of caller adherence to a health care facility referral. METHODS: A focus group was conducted with 6 nurses and 4 pharmacists from a regional PCC. Content analysis was used to determine themes within the discussion. All participants were certified as specialists in poison information (SPIs). RESULTS: Four themes were identified: (1) SPIs' generation of informal "likelihood-of-adherence" assessments as to whether a caller will follow the recommendation to go to a health care facility, (2) SPI communication strategies used to promote adherence, (3) behavior of SPIs during periods of high call volume, and (4) communication training for PCC staff members. DISCUSSION: This pilot study provides insights in SPIs' current assessment and communication, particularly those related to promoting caller adherence to recommendations.

Building knowledge for poison control: the novel pairing of communication analysis with data mining methods.

As information systems become increasingly integrated with health care delivery, vast amounts of clinical data are stored. Knowledge discovery and data mining methods are potentially powerful for the induction of knowledge models from this data relevant to nursing outcomes. However, an important barrier to the widespread application of these methods for induction of nursing knowledge models is that important concepts relevant to nursing outcomes are often unrepresented in clinical data. For instance, communication approaches are not necessarily consciously chosen by nurses, yet they are known to impact multiple clinical outcomes including satisfaction, pain and symptom response, recovery, physiological change (e.g., blood pressure), and adherence. Decisions about communication behaviors are likely intuitive and instantaneously made in response to cues offered by the patient. For this reason, among others, important choices and actions of nurses are not routinely documented. And so for many clinical outcomes relevant to nursing, important concepts such as communication are not represented in clinical data repositories. In studying poison control center outcomes, it is important to consider not only routinely documented clinical data, but the communication processes and verbal cues of both patient and SPI. In a novel approach, our current study of poison control center outcomes pairs a qualitative study of the communication patterns of SPIs and callers to a regional poison control center, with predictive modeling of poison control center outcomes using knowledge discovery and data mining methods. This three year study, currently in progress, pairs SPI-caller communication analysis with predictive models resulting from the application of knowledge discovery and data mining methods to three years' of archived clinical data. The results will form a hybrid model and the basis for future decision support interventions that leverage knowledge about both implicit and explicit factors that contribute to poison control center outcomes.

Requirements analysis for HL7 message development in poison control center.

HL7 is the commonly accepted messaging standard for achieving interoperability among information systems. Until now, no analysis has been done on how poison control data can be matched in HL7 messages. The purpose of this study was to create a preliminary domain analysis model which can be used to identify the data required to message poison control data in HL7 messages.

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.

Poison control center communication and impact on patient adherence.

OBJECTIVE: This project explored the communication processes associated with poison control center calls. METHODS: In this preliminary study, we adapted the Roter Interaction Analysis System to capture staff-caller dialogue. This involved case selection, wherein adherence and non-adherence cases were selected; call linkage to medical records, where case records were linked with voice recordings; and application of Roter Interaction Analysis System to calls. RESULTS: Results indicate that communications are predominantly provider-driven. Patient age and percentage of staff partnership statements were significantly associated with adherence at the 0.05 level. Increases in age were associated with decreases in adherence to recommendations (p < 0.001). Increases in percentage of staff partnership statements (over all staff talk) were associated with increases in adherence (p = 0.013). CONCLUSION: This line of research could lead to evidence-based guidelines for effective staff-caller communication, increased adherence rates, and improved health outcomes.

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.

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.

Prospective observational multi-poison center study of ziprasidone exposures.

BACKGROUND: Ziprasidone is an atypical antipsychotic associated with QTc prolongation during therapeutic use. We characterized the clinical manifestations associated with ziprasidone overdoses, in particular the incidence and severity of QTc prolongation. METHODS: Four regional poison centers prospectively collected ziprasidone overdose data from August 1, 2003 to October 1, 2005. Cases were included if they were followed to known medical outcome and comprised single-substance ziprasidone exposures or with co-ingestants not associated with prolongation of the QTc interval. RESULTS: Fifty-six ziprasidone exposures met inclusion criteria. The most common clinical effects were drowsiness (N=38, 67.9%) and tachycardia (N=19, 33.9%). QTc prolongation (>0.500 second) occurred in only one patient. Seven patients had QTc intervals of 0.450 to 0.500 second. Medical outcomes were coded as no effect (13, 23.2%), minor effect (21, 35.5%), moderate effect (20, 35.7%), or major effect (2, 3.4%). CONCLUSION: Common clinical effects following ziprasidone overdose are drowsiness and tachycardia. Clinically significant QTc prolongation occurs infrequently.

Matching waveform audio files with toxicall data: Record linkage in a poison control center.

Analysis of coded communications and electronic patient record data present a unique opportunity for nursing knowledge discovery, the integration of communication content with clinical data. However, joint analysis of coded communications and clinical data depends on the ability to link waveform audio files with patient records. A procedure has been developed to link waveform audio files with Toxicall patient records, using date/time stamps and station identification numbers.

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.

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.

Differences in herbal and dietary supplement use in the Hispanic and non-Hispanic pediatric populations.

BACKGROUND: Complementary and alternative medical therapies are becoming increasingly popular in the general population. OBJECTIVE: To describe the cultural differences in the use of herbal and dietary supplements in the Hispanic and non-Hispanic-Caucasian outpatient pediatric populations. METHODS: Questionnaires were administered over a 2-month period to a convenience sample of adolescents and parents of patients younger than 12 years, presenting to an emergency department, an urban private pediatric practice, and a community-based clinic. RESULTS: There were 643 surveys completed. Ethnic distribution was 65% Caucasian, 27% Hispanic, 2% Pacific Islander, and 1% each Asian, African American and Native American. Mean respondent age was 30.8 years. Mean child age was 4.6 years; 51% were male. Use of nonprescribed dietary supplements was significantly greater in Hispanic (33%) versus Caucasian children (9%) (P < 0.01); most commonly used supplements were herbal teas (56%) and echinacea (14%). More Hispanic respondents reported receiving information on herbal preparations from a family member compared with non-Hispanic patients (56.0% vs. 18.7%). Complementary and alternative medicine use had not been discussed with a health care provider by 38% of the total users and 47% of those thought it not important to do so. CONCLUSIONS: There is significant use of complementary and alternative medicine in the pediatric population, and herbal and dietary supplement use varies between Hispanic and Caucasian children. In addition, this dietary supplement use is often not discussed with health care providers. These factors should be taken into consideration by all health care providers.

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.