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Toxicological emergencies present a significant health challenge in Nepal. Despite the high burden, the country has inadequate formal toxicology training, medical toxicology expertise, and adequate poison control infrastructure. In recognition of this need, the Nepal Poison Information Center (PIC) was established as a collaborative effort involving local and international partners. Through a comprehensive partnership framework, the Nepal PIC provides 24 hours a day, 7 days a week expert guidance to health care workers, conducts educational webinars, and engages in research. Initial data from the pilot phase indicate successful consultation delivery. Challenges include bureaucratic hurdles and the need for sustainable funding. Despite these challenges, the Nepal PIC demonstrates early feasibility and potential for expansion into a comprehensive toxicology center, contributing to the advancement of clinical toxicology in Nepal. Long-term sustainability relies on governmental support and continued advocacy efforts., (© Kharel et al.)

Introduction: In response to the opioid epidemic, California state officials sought to fund a variety of projects aimed at reducing opioid-related deaths. We describe the California Poison Control System's (CPCS) successful effort in integrating itself into the state's public health response to the opioid epidemic and describe poison control center staff attitudes and perceptions regarding the role of poison control centers at treating opioid withdrawal and addiction., Methods: The CPCS created a leadership team and a separate 24/7 hotline, called the CPCS-Bridge line, to field calls from frontline health care providers interested in initiating medications for opioid use disorder for their patients. The implementation process also included training of all CPCS staff. In addition, the leadership team conducted an anonymous survey study to analyze attitudes and perceptions of poison center staff on the role of the poison center in the management of opioid use disorder. Descriptive statistics were used to characterize the data., Results: Calls to the new hotline increased over time, along with CPCS-initiated outreach and advertisement. A majority of questions received by the hotline were related to uncomplicated buprenorphine starts in special populations. A pre-training survey was completed by 27 (58%) of CPCS specialists, many of whom had no prior experience treating patients with opioid use disorder. Only one specialist (2%) did not believe that poison centers should play a role in opioid addiction., Conclusions: The California Poison Control System successfully created a hotline to assist frontline health care providers in treating patients with opioid use disorder and highlight the critical role of poison centers in the public health domain. Increased federal funding to poison centers is likely to be mutually beneficial to all parties involved.

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., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Aims: Presentations of intoxicated patients to hospital are frequent and increasing. We aimed to review the existing evidence that the presence of inpatient clinical toxicology services reduces use of resources without impacting on the care of these patients., Methods: We conducted a literature search using the Cochrane Library, PubMed, and Embase for articles that measured length of stay (and other outcomes) for the target population, with toxicology services as an intervention. The articles were reviewed with respect to the ROBINS-I tool., Results: Seven relevant articles were identified. Six of these studies demonstrated reduced hospital length of stay for intoxicated patients in hospitals with inpatient toxicology services. None of the articles demonstrated a detriment in morbidity or mortality. There were also improvements in other resource-related outcomes., Conclusions: The presence of inpatient toxicology services appears to improve resource utilization, in reduction of length of stay, as well as a number of other related outcomes. It does this without compromising on patient morbidity or mortality. Thus, it should be considered as a potential model of care for future toxicology services, especially with current trends of increasing demand for service efficiency., (© 2018 The British Pharmacological Society.)

Introduction: Morbidity and mortality from poison- and drug-related illness continue to rise in the USA. Medical toxicologists are specifically trained to diagnose and manage these patients. Inpatient medical toxicology services exist but their value-based economic benefits are not well established., Methods: This was a retrospective study where length of stay (LOS) and payments received between a hospital with an inpatient medical toxicology service (TOX) and a similar hospital in close geographic proximity that does not have an inpatient toxicology service (NONTOX) were compared. Controlling for zip code, demographics and distance patients lived from each hospital, we used a fitted multivariate linear regression model to identify factors associated with changes in LOS and payment., Results: Patients admitted to the TOX center had 0.87 days shorter LOS per encounter and the hospital received an average of $1800 more per patient encounter., Conclusion: In this study, the presence of an inpatient medical toxicology service was associated with decreased patient LOS and increased reimbursement for admitted patients. Differences may be attributable to improved direct patient care provided by medical toxicologists, but future prospective studies are needed.

Objective: Affected women and health professionals are still often unsure about how to react to exposures to potentially harmful agents during pregnancy. We wanted to find out which agents worry both pregnant women and professionals, under what circumstances the exposures take place, how they are currently dealt with and how serious they are., Methods: Making use of the archives of Tox Info Suisse, the foundation that provides poisons information in Switzerland both for members of the general public and for healthcare professionals, we set up an analysis of exposures to possibly harmful agents during pregnancy. Queries during pregnancy between 1995 and 2015 were analysed. Demographic information, exposure and agent characteristics as well as - in a subgroup of cases - the corresponding treatments were considered in the present descriptive, retrospective analysis., Results: Over the 21-year period, 2871 exposures during pregnancy were identified. The majority of the calls were made by members of the general public (2035, 70.9%; most often by the affected women themselves), followed by physicians (733, 25.5%). General public queries were mostly due to exposures connected with household chemicals (675/2035, 33.2%); those of physicians were most often due to medications (415/733, 56.6%). The majority of agent exposures occurred accidentally at home, at work, outdoors or at various other places (2297/2871, 80.0%). Less frequently, the exposures were intentional and had a suicidal, abusive, criminal or other character (471/2871, 16.4%). Of the 2871 calls, 905 cases with symptoms were recorded. Of the 1268 symptoms, 820 were mild (64.7%), 144 moderate (11.3%), 24 severe (1.9%, including 12 abortions) and 280 were not further specified (22.1%). In 1867 cases (65%), a total of 2331 measures were recommended by Tox Info Suisse, 1961 thereof to be carried out immediately. The two most common immediate measures were exposure interruption (412/1961, 21.0%) and forwarding to another institution (345/1961, 17.6%). In 70 cases, physicians' follow-up reports could be analysed; paracetamol was the agent most frequently involved (15 cases), followed by mefenamic acid (9) and the household product sodium hypochlorite (9)., Conclusions: Tox Info Suisse recorded an average of 137 cases of agent exposure during pregnancy per year, mostly due to accidents with household products. Suicidal intentions played a role in a considerable number of exposures. Measures are needed to prevent accidental exposure of pregnant women to toxic substances and to support them in this exceptional life period.

Introduction: Salicylate poisoning is a serious toxicologic problem with a complex pathophysiology that requires prompt diagnosis and action for a favorable outcome. A simulated experience in the evaluation and management of an aspirin-overdose patient allows learners to construct a differential diagnosis from an array of symptoms and signs, analyze a mixed acid-base disturbance, and explore the multistep management of this disorder., Methods: This simulation exercise was designed for second-year medical students. At the start of the session, teams received a 10-minute introduction to the activity. Upon entering a room in a simulated Emergency Department, teams had 15 minutes to complete a focused history and physical exam of the patient, interpret arterial blood gas and basic metabolic panel data, and administer treatment based on key findings and a presumptive diagnosis. The scenario was followed by a 90-minute facilitated debriefing session. An alternative 45-minute debriefing guideline is also included., Results: Students voluntarily completed a 13-question, 5-point Likert-scale survey about the educational exercise immediately following the session. They evaluated the preparatory materials and briefing, the simulation scenario, the usefulness of the debriefing, and their confidence in their understanding of salicylate poisoning following the session. Students reported a favorable response to the overall experience and the debriefing, as well as an increase in confidence following the session., Discussion: This simulation exercise was successful in exposing students to the clinical presentation of salicylate toxicity and giving them the opportunity to apply and synthesize basic science knowledge during the scenario., Competing Interests: None to report.

Background: The public commonly calls 911 for unintentional ingestions, rather than calling the local poison center. By utilizing a series of scripted questions, 911 dispatchers in Los Angeles determine if an ingestion meets "omega-1" classification. Under such circumstances, the regional poison center is contacted prior to dispatch of paramedics. If the poison center advises that the patient can remain at home, EMS is not dispatched and the patient is followed at home by the poison center. The primary objective is to determine the number of averted transports through involvement of a poison center. A secondary objective is to determine the potential costs and charges saved with the use of such a strategy., Methods: A retrospective review of all overdose calls with an "omega-1" classification to a single EMS system between 1/2008-6/2012. Each call culminating in an EMS dispatch was subsequently reviewed by two additional reviewers. The cost savings was determined by utilizing data from the Medical Expenditure Panel Survey (MEPS) from 2000 to 2010. Monetary values were adjusted to 2012 dollars., Results: Three hundred eighteen cases received "omega-1" dispatch classification. EMS was dispatched 19 times (5.98 %), and 11 patients (3.46 %) were ultimately transported. The most common reasons for transport were ambiguity over the ingested agent or amount, and caller insistence. Using these estimates, routine consultation of a regional poison center as part of EMS dispatch averted $486,595 in charges, and $183,279 in payments., Conclusions: Routine consultation of a poison center by emergency medical dispatchers can reduce unnecessary dispatches, ambulance transports, and ED visits with significant associated cost savings.

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., (© The Author 2014. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: In this paper the structure of poisonings is described, based on the material collected from tele-toxicology consults by the Pomeranian Center of Toxicology in Gdańsk and harvested from its Electronic Poison Information Management System. In addition, we analyzed conclusions drawn from a 27-month operation of the system., Material and Methods: Data were harvested from the Electronic Poison Information Management System developed in 2012 and used by the Pomeranian Center of Toxicology since then. The research was based on 2550 tele-toxicology consults between January 1 and December 31, 2014. Subsequently the data were electronically cleaned and presented using R programming language., Results: The Pomeranian voivodeship was the prevalent localisation of calls (N = 1879; 73.7%). Most of the calls came from emergency rooms (N = 1495; 58.63%). In the case of 1396 (54.7%) patients the time-lag between intoxication and the consult was less than 6 h. There were no differences in the age distribution between genders. Mean age was 26.3 years. Young people predominated among intoxicated individuals. The majority of intoxications were incidental (N = 888; 34.8%) or suicidal (N = 814; 31.9%) and the most of them took place in the patient's home., Conclusions: Information about Poison Control Center consultations access should be better spread among medical service providers. The extent of poison information collected by Polish Poison Control Centers should be limited and unified. This should contribute to the increased percentage of properly documented consultations. Additional duties stemming from the need of digital archiving of consults provided, require the involvement of additional staff, leading to the increased operation costs incurred by Poison Control Centers., (This work is available in Open Access model and licensed under a CC BY-NC 3.0 PL license.)

The impact of a severe influenza pandemic could be overwhelming to hospital emergency departments, clinics, and medical offices if large numbers of ill people were to simultaneously seek care. While current planning guidance to reduce surge on hospitals and other medical facilities during a pandemic largely focuses on improving the "supply" of medical care services, attention on reducing "demand" for such services is needed by better matching patient needs with alternative types and sites of care. Based on lessons learned during the 2009 H1N1 pandemic, the Centers for Disease Control and Prevention and its partners are currently exploring the acceptability and feasibility of using a coordinated network of nurse triage telephone lines during a pandemic to assess the health status of callers, help callers determine the most appropriate site for care (eg, hospital ED, outpatient center, home), disseminate information, provide clinical advice, and provide access to antiviral medications for ill people, if appropriate. As part of this effort, the integration and coordination of poison control centers, existing nurse advice lines, 2-1-1 information lines, and other hotlines are being investigated.

For years, The American Academy of Pediatrics (AAP) had supported home use of syrup of Ipecac. However, due to mounting evidence that Ipecac use did not improve outcome nor reduce Emergency Department (ED) referrals, the AAP in November of 2003 issued a statement that Ipecac not be used for the home management of poison ingestion. To determine if the cessation of the use of Ipecac for home ingestions is associated with an increased number of follow-up calls, an increased time of observation at home and an increase in the number of ED referrals for care by poison center staff were administered. Fifty randomly selected pediatric (<6 years) cases that received Ipecac ("Ipecac" group) from January 1, 2003 to October 31, 2003 were selected for study. Up to two controls ("no Ipecac" group) were matched by age, amount ingested, and by toxin. Controls were selected from the 2004-2006 time period (Ipecac no longer in use). Fifty "Ipecac" cases and 84 "no Ipecac" controls were analyzed. The groups had no significant differences with respect to percent symptomatic, median time post-ingestion, mean age, and distribution of toxin categories (e.g., antidepressants, beta blockers, etc.). The "no Ipecac" group had nearly ten times the odds of ED referral compared to the "Ipecac" group, (OR = 9.9, 95%CI 3.3-32.2). The mean total hours of follow-up was not significantly different between the groups (diff = -1.1, t = -1.8, p = 0.07). The mean number of follow-up calls was significantly less in the "no Ipecac" group (diff = -1.4 calls, t = -6.8, p < 0.001). Toxicology consults were greater in the "no Ipecac" group (chi (2 )= 4.05, p = 0.04); however, consults were not associated with ED referral. For the time period from 2004 to 2006, the "no Ipecac" policy resulted in an increase in ED referrals at our center. While prior studies have shown that not using Ipecac did not affect clinical outcome, our research suggested that it may have initially influenced triaging outcome. Since the use of Ipecac by centers was once a commonly used home remedy for some ingestions (albeit without rigorously established efficacy), poison center personnel had to transition to the "no Ipecac" policy. Although our referrals increased during a transitional period of time, referral rates have since stabilized and returned to baseline.

1. Detecting medication errors needs collaboration between various organizations, such as patient safety institutions, pharmacovigilance centres, and poison control centres. In order to evaluate the input of pharmacovigilance centres and poison control centres in detecting and evaluating medication errors a pilot project was initiated by the World Alliance for Patient Safety in collaboration with the Uppsala Monitoring Centre; the Moroccan pharmacovigilance centre acted as project coordinator. As part of this project, a questionnaire on detecting medication errors was circulated to pharmacovigilance centres and poison control centres around the world, in order to assess their ability to detect and analyse medication errors. 2. The results showed that through their databases pharmacovigilance centres can detect, identify, analyse, and classify medication errors and carry out root cause analysis, which is an important tool in preventing medication errors. 3. The duties of pharmacovigilance centres in preventing medication errors include informing health-care professionals about the importance of reporting such errors and creating a culture of patient safety. Pharmacovigilance centres aim to prevent medication errors in collaboration with poison control centres. Such collaboration allows improved detection and improved preventive strategies. In addition, collaboration with regulatory authorities is important in finalizing decisions. 4. Collaboration between pharmacovigilance centres and poison control centres should be strengthened and bridges need to be built linking pharmacovigilance centres, poison control centres, and organizations dedicated to patient safety, in order to avoid duplication of workload.

Background: The Palestinian Poison Control and Drug Information Center was established in 2006 to provide up-to-date information on medications and to help in the early diagnosis and management of poisoning cases., Objectives: To summarize the activities carried out by the PCDIC in the past 2 years., Methods: Documented inquires received at the PCDIC were analyzed and the Center's activities were extracted from the files., Results: During the first 2 years of the Center's existence, 323 enquiries were received, mainly (67.2%)from physicians; 70% of the calls were from the city of Nablus. Unintentional poisoning was the leading type of call (62.8%) followed by suicidal poisoning (20.7%). Medications were the major category of toxicants encountered (48.9%), followed by pesticides (23.5%). In 67.9% of the cases, the calls were initiated before any treatment was provided. The advice provided by the PCDIC was based on the nature of the call. During these 2 years the PCDIC has conducted both academic and non-academic activities. The Center introduced the concept of poison prevention weeks in Palestine and has conducted two so far. The PCDIC has published several articles in the fields of toxicology, rational drug use, complementary and herbal therapy, pharmacoepidemiology, and self-medication., Conclusions: Documentation of all enquiries is mandatory for analysis, evaluation, comparative purposes and quality assurance. More information campaigns are needed to encourage people to use the services provided by the PCDIC.

Emergency departments throughout the USA may have some familiarity with the management of envenomation from indigenous snake species such as Crotalinae (rattlesnakes) and Micrurus (coral snakes). However, venomous species may include exotic reptiles whose bites pose substantial treatment challenges due to both a lack of experience and the difficulty in obtaining antivenoms. Two pet cobra envenomation incidents illustrate the challenges that face emergency departments, especially in urban settings, that are confronted with these exposures. It is important for emergency departments to be aware of the large underground presence of exotic venomous reptile pets and to utilise the expertise of regional poison centres that will also assist in the procurement of exotic antivenoms.

Antidotes (ANT) are lifesaving drugs that must be timely administered in case of poisoning, but their availability when and where needed is often a problem. The experience of setting up a web-based national network aimed at sharing ANT availability information is described, together with the steps followed to make it be an effective solution.

Poisons centres throughout Italy and Europe vary considerably in terms of their institutions and organisation. The European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) has laid down the activities that a poisons centre must carry out, specifying minimum and maximum standards required. These directions allow an evaluation of the service provided. In 2002 Milan Poisons Centre began a project aiming to introduce concepts and methodology proper of the quality systems within poisons centres' institutional activity. Concluded, the project resulted in the centre's certification and the documentation of its procedures: this may now contribute to help define the status and activity of poisons centres in Italy.

Timely pre-hospital management of snake bite and poisoning cases is hindered by the lack of information about availability of antidotes in hospitals. We aim to build a regional antidote database by collecting real-time antidote stock information from hospital pharmacy inventory systems and make this information available to the emergency medical technicians (EMTs). This would save valuable time, leading to improved outcomes for the patients.

Background: National surveillance for chemical incidents is being developed in the UK. It is important to improve the quality of information collected, standardise techniques, and train personnel., Objective: To define the extent to which eight National Poison Information Service specialists in poison information agree on the classification of calls received as "chemical incidents" based on the national definition., Design: Blinded, inter-rater reliability measured using the kappa statistic for multiple raters., Setting: National Poison Information Service and Chemical Incident Response Service, Guy's and St Thomas's NHS Trust, London., Participants: Eight specialists in poison information who are trained and experienced in handling poisons information calls and have been involved in extracting information for surveillance., Results: The overall level of agreement observed was at least 69% greater than expected by chance (kappa statistic). Fire and incidents where chemicals were released within a property had a very good level of agreement with kappa statistic of 83% and 80% respectively. The lowest level of agreement was observed when no one or only one person was exposed to a chemical (33%) and when the chemical was released into the air (48%)., Conclusion: High levels of agreement were observed. There is a need for more training and improvement in consistency of the data collected by all organisations.

Background: Exposure to drugs and toxins is a major cause for patients' visits to the emergency department (ED)., Methods: Recommendations for the use of clinical laboratory tests were prepared by an expert panel of analytical toxicologists and ED physicians specializing in clinical toxicology. These recommendations were posted on the world wide web and presented in open forum at several clinical chemistry and clinical toxicology meetings., Results: A menu of important stat serum and urine toxicology tests was prepared for clinical laboratories who provide clinical toxicology services. For drugs-of-abuse intoxication, most ED physicians do not rely on results of urine drug testing for emergent management decisions. This is in part because immunoassays, although rapid, have limitations in sensitivity and specificity and chromatographic assays, which are more definitive, are more labor-intensive. Ethyl alcohol is widely tested in the ED, and breath testing is a convenient procedure. Determinations made within the ED, however, require oversight by the clinical laboratory. Testing for toxic alcohols is needed, but rapid commercial assays are not available. The laboratory must provide stat assays for acetaminophen, salicylates, co-oximetry, cholinesterase, iron, and some therapeutic drugs, such as lithium and digoxin. Exposure to other heavy metals requires laboratory support for specimen collection but not for emergent testing., Conclusions: Improvements are needed for immunoassays, particularly for amphetamines, benzodiazepines, opioids, and tricyclic antidepressants. Assays for new drugs of abuse must also be developed to meet changing abuse patterns. As no clinical laboratory can provide services to meet all needs, the National Academy of Clinical Biochemistry Committee recommends establishment of regional centers for specialized toxicology testing.

Unprecedented poisoning terrorism by use of sarin took place in Japan in 1994 and 1995. On July 25, 1998, a curry poisoning incident in Wakayama occurred resulting in the death of four people and injury of 63 people. Since then, more than 30 imitative poisoning cases have been reported by mass communication within 1 year. In this brief review, we present some details of a series of poisoning cases and measures taken by the Japanese Government and non-government groups. In addition some research projects on analytical toxicology being conducted in our laboratories are also introduced; gas chromatography (GC) with cryogenic oven trapping for volatile organic compounds, and GC/surface ionization organic mass spectrometry for tertiary amino compounds are described especially as new techniques for biological samples.

The Hawaii Poison Center was established because poisoning was a significant public health problem in the 1950s. The history and status of the Center, in the context of national trends and key issues in poison control public health infrastructure, is reviewed.

Responding to the need for a poison information, education, data collection and research resource in California's Bay Area and North Coast counties, the San Francisco Bay Area Regional Poison Control Center has become an integral part of the region's emergency medical services. In the first 33 months after it opened, more than 54,000 calls for assistance were received, nearly a third from medical professionals. Through the cooperation and collaboration of public, private and university resources and interests, a cost-effective, comprehensive and accessible system has evolved for public and professional use. Through our experience a system has developed that can serve as a model for poison information services throughout the western states. Emerging public concern for toxicology issues will continue to refine this model.