Forging a Poison Prevention and Control System available in Hardcover
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Poisoning is a far more serious health problem in the U.S. than has generally been recognized. It is estimated that more than 4 million poisoning episodes occur annually, with approximately 300,000 cases leading to hospitalization. The field of poison prevention provides some of the most celebrated examples of successful public health interventions, yet surprisingly the current poison control "system" is little more than a loose network of poison control centers, poorly integrated into the larger spheres of public health. To increase their effectiveness, efforts to reduce poisoning need to be linked to a national agenda for public health promotion and injury prevention.
Forging a Poison Prevention and Control System recommends a future poison control system with a strong public health infrastructure, a national system of regional poison control centers, federal funding to support core poison control activities, and a national poison information system to track major poisoning epidemics and possible acts of bioterrorism. This framework provides a complete "system" that could offer the best poison prevention and patient care services to meet the needs of the nation in the 21st century.
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FORGING A Poison Prevention AND Control System
NATIONAL ACADEMIES PRESS
Copyright © 2004 National Academy of Sciences
All right reserved.
The Institute of Medicine (IOM) was asked by the Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration (HRSA) to assist in developing a more systematic approach to understanding, stabilizing, and providing long-term support for poison prevention and control services. Within this context the Committee was asked to examine the future of poison prevention and control services in the United States. The specific tasks included in the charge are provided in Box ES-1. In order to respond fully and specifically to the charge, the Committee adopted the very language used by HRSA: to consider the "future of poison prevention and control services" and to develop a "systematic" approach. Therefore, we examined the role of poison control services within the context of the larger public health system, the injury prevention and control field, and the fields of general medical care and medical and clinical toxicology. Furthermore, we examined how poison control centers function relative to the functions performed by other health care agencies and government organizations at the federal, state, and local levels.
Poisoning is a much larger public health problem than has generally beenrecognized, and no comprehensive system is in place for its prevention and control. To address its charge of creating such a system, the IOM Committee faced two major, overarching issues. The first of these was a definitional problem-there is simply no universally agreed upon definition of poisoning from either a clinical or epidemiological perspective. Thus, in order to assess the magnitude, scope, and boundaries of the area under study, the Committee adopted an operational definition of poisoning without attempting to resolve all the classification disputes about specific elements of the definition. The second major issue concerned the historical development of the poison control centers and their position in the broader fields of public health and emergency medical services. In order to make recommendations about stabilizing and providing long-term support to the network of centers, the Committee developed a vision for the future organization, structure, and funding of a poison prevention and control system.
THE DEFINITION, SCOPE, AND MAGNITUDE OF POISONING
The Committee's operational definition of poisoning subsumes "damaging physiological effects of ingestion, inhalation, or other exposure to a range of pharmaceuticals, illicit drugs, and chemicals, including pesticides, heavy metals, gases/vapors, and common household substances, such as bleach and ammonia" (Centers for Disease Control and Prevention, 2004, p. 233). The Committee's approach to defining poisoning is addressed in Box ES-2. A broad clinical definition of human poisoning, as noted above, captures any toxin-related injury. However, each agency that collects data or provides services in this arena has evolved its own particular definitional boundaries of the poisoning problem. Furthermore, definitions of a poisoning and its place among other medical diagnoses vary from the 9th to the 10th revisions of the International Classification of Diseases, the system that drives health data categorization at both the federal and state levels. Finally, the network of poison control centers has evolved its own operational definition of what constitutes an "exposure" to a poisonous substance. As a result, the Committee adopted an operational definition of poisoning that could be used to analyze the available datasets to better understand the magnitude of the poison problem (see Chapter 3 for expanded discussion of this question).
The Committee estimates that more than 4 million poisoning episodes (actual or suspected exposures) occur in the United States annually, with approximately 300,000 cases leading to hospitalization. The poisoning death rate increased by 56 percent between 1990 and 2001 (Centers for Disease Control and Prevention, 2004). In 2001, poisoning was the second leading cause of injury-related mortality, accounting for an estimated 30,800 deaths annually. A conservative estimate of the economic burden of poisoning not including costs related to alcohol deaths is $12.6 billion per year (2002 dollars), based on the societal lifetime cost of injury.
Poisoning is a public health problem across the entire lifespan. It is well recognized that unintentional exposure to hazardous household substances (including medications found in the home) occurs mainly among preschool-aged children; the majority of these exposures can be treated in the home and the associated mortality rate is low. It is less well appreciated that the burden of unintentional drug overdose and suicide deaths is more likely to occur among adolescents and young adults, and that the elderly are at high risk for poisoning due to scenarios such as mixing medications or taking the wrong dosage. Finally, new concerns about biological and chemical terrorist acts have elevated poisoning to a national security issue of public health importance. Poison control centers respond to calls from the public in all of these areas; although approximately 50 percent of calls concern possible exposures to children 5 years of age and under, approximately 7.6 percent are suspected suicides, and another 3.5 percent are cases of substance misuse or abuse. Furthermore, 3 percent of the calls are categorized as alcohol related.
The national goals for reducing poisoning mortality and morbidity, established by Healthy People 2010, did not fully recognize this broader picture of the importance of poisoning in the United States. The specific objectives as cited are to reduce nonfatal poisonings to 292 per 100,000 population (based on emergency department visit incidence) and deaths caused by poisoning to 1.5 per 100,000 population. According to the Committee's estimates of the current level of poisoning (2001 data)-530 poisonings per 100,000 population and 8.5 deaths per 100,000 population-these goals are unlikely to be reached by 2010.2 The Committee concludes that the national efforts to reduce poisoning must be linked to a national agenda for public health promotion and disease prevention. We envision a future Poison Prevention and Control System that is integrated with the medical care system and public health and that includes a network of poison control centers as a vital, but not exclusive, element.
In approaching its work, the Committee recognized that the public-access peer-reviewed literature on poison control centers did not provide an adequate evidentiary base to answer the charge. As a result, the Committee conducted a series of analyses using existing databases and engaged in primary data collection to develop a more in-depth understanding of current poison control center services and organizational structures. The review and analysis focuses on, but is not limited to, the current characteristics of poison control centers and the challenges for the future regarding prevention, service delivery, and surveillance.
The current network of poison control centers in the United States has developed to meet local needs and is supported for the most part by local resources. There is no coordinated national system. The evolution from the earliest center in 1953 has been individualized and chaotic; at one point, in 1978, there were as many as 661 poison control centers, many of them serving relatively small populations. Now there are 63 poison control centers covering various regions that collectively serve nearly the entire U.S. population. These centers offer a critical set of services to the public and health care professionals by providing timely, professional treatment advice in response to telephone queries concerning poisoning exposures. According to the American Association of Poison Control Centers (AAPPC), in 2002 more than 2.3 million human exposure calls were received by all centers combined. As noted earlier, calls to poison control centers are classified as human exposure (to poison) if a member of the public or health care community is reporting an actual or suspected poisoning exposure. Thus, not all human exposure calls are poisonings. For each such call, both the suspected exposure reported by the caller and the treatment response by poison control center staff are recorded. Thus a wealth of data on reported poisoning exposures is generated. Finally, poison control centers provide an important training ground for medical toxicologists, nurses, nurse managers, pharmacists, and other health care professionals.
Unfortunately, the current "network" of poison control centers suffers a number of shortcomings. First, it is financially unstable, with each center drawing its support from numerous federal, state, and local sources that are frequently undergoing fiscal challenges and budget adjustments. The Poison Control Center Enhancement and Awareness Act of 2000, amended in 2003, was enacted to stabilize center operations. Although these funds are intended to provide an emergency safety net, their magnitude and focus on supporting new activities rather than existing staff and infrastructure do not ensure consistent, effective, and efficient delivery of poison prevention and control services to the U.S. population. In the past year alone, two poison control centers lost their funding and were forced to close; other centers expend considerable time and effort obtaining needed support. Second, the current network of poison control centers operates, in key aspects, in a manner that could be characterized as a collection of independent organizations rather than as a "system." As a result, there is insufficient sharing of strategies and resources. Third, there is no effective link to the nation's public health system that provides a seamless net of services in prevention, injury control, and all-hazards emergency preparedness. Fourth, the current poison control center data collection and reporting system, known as the Toxic Exposure Surveillance System (TESS), functions as a proprietary system that is not fully available to the work of federal and state agencies engaged in protecting the population from consumer product or intentional hazards.
CONCLUSIONS AND RECOMMENDATIONS
The Committee concluded, based on its research and discussions, that the current network of poison control centers does not constitute the complete "system" of poison prevention and control services needed by the nation in the 21st century. Such a system must provide the best prevention and patient care services for the diverse population of Americans who are exposed to hazardous substances and protect the nation from the threats associated with biological and chemical terrorist events and other emerging public health emergencies. Therefore, the Committee based its report on a proposed Poison Prevention and Control System, including within it a network of poison control centers as a vital, but not exclusive, element. The Committee also concluded that in order to fulfill their pivotal role in the overall system, poison control centers must be more stable financially and better integrated and coordinated for performance of their public health roles.
The Committee considered the strengths and weaknesses of a variety of options for the number and distribution of poison control centers in a Poison Prevention and Control System. Although modern telecommunications technology makes it feasible to consider one single, highly efficient, large center serving the entire country, the Committee found a number of weaknesses with that model. A single national center would have difficulty appreciating local variations in poisonous substances such as plants and insects. In addition, a single center would concentrate all the expertise in one location, thereby eliminating important and timely local medical consultations. Finally, a single center is vulnerable to practical problems of power failures, limited surge capacity, and potential transmission lags during times of high volume. The Committee also considered a national model that would have a single poison control center in each state. This model was also rejected as inconsistent with the current realities. A number of states with relatively small and dispersed populations have chosen to contract with larger centers to meet their needs. Also, in large states like California, there is a statewide system with multiple centers because one single center alone cannot meet the entire need. Thus, the Committee concluded that a system of regional centers would provide an appropriate balance of size and responsiveness.
The rationale for a regionalized system includes the following elements. Poison control centers must be large enough to sustain an adequate-sized staff to meet usual demands and the surge capacity required to respond to situations of mass poisoning or suspected terrorism events. A regional distribution of such centers would satisfy the need to distribute medical toxicological leadership across the United States to address the diversity of poison exposures and to provide firsthand consultation to hospitals and physicians. The interaction among regionally based centers would promote innovation and the sharing of best practices. Finally, a regionalized system should provide enough redundancy in skills and resources to meet surge needs and potential equipment failures.
The Committee concluded that decisions about the number of centers should be based on considerations of population coverage, telecommunication capabilities, and types of funding. While the currently available data are not adequate to prescribe a specific size or geographical coverage for centers, the Committee believes there may be economies of scale and scope that can be achieved through a regionalized system. Defining a set of core services will support the development of a federal funding formula for regionalized poison control centers. Ultimately, the needs assessment data must be developed to define the financial and services base for developing contractual agreements for poison control services. The Committee believes that the concept of regionalized national poison control centers is critical to the development of the Poison Prevention and Control System.
The Committee's recommendations form the basis for the Poison Prevention and Control System. They are grouped according to the areas listed in the Committee's charge:
Scope of core poison prevention and control activities
Coordination of poison control centers with other public health entities
Strengths and weaknesses of poison control center organizational structures
Financial support for the Poison Prevention and Control System
Assurance of high-quality poison control center services
National data system and surveillance needs
Scope of Core Poison Prevention and Control Activities
The Committee identified a core set of activities that constitutes the essential functions of the network of poison control centers within the larger system envisioned by the Committee. Although these activities are already being carried out, it is essential to identify them as a set of core activities so that they become the basis for consistent funding under the aegis of the proposed expanded federal legislation. These activities are considered by the Committee to be core because (1) they represent critical components of current and future poison control efforts; (2) the structure of poison control centers and expertise of their staffs make them uniquely capable of performing these activities (i.e., there are no other organizations in the public health and health care arena that can perform these activities at the same level of excellence and cost); and (3) they provide an infrastructure to which other related activities can readily be added as required. The notion of core activities does not imply that poison control centers should confine their activities solely to these areas. The addition of other activities should be based on local capabilities and opportunities for funding. Examples include undertaking clinical toxicology research or providing training for health care students who are not specifically focused on careers in medical or clinical toxicology.
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Table of Contents
|2||Toward a Poison Prevention and Control System||34|
|Part II||Current Status and Opportunities|
|3||Magnitude of the Problem||43|
|4||Historical Context of Poison Control||80|
|5||Poison Control Center Activities, Personnel, and Quality Assurance||106|
|6||Current Costs, Funding, and Organizational Structures||136|
|7||Data and Surveillance||176|
|8||Prevention and Public Education||201|
|9||A Public Health System for Poison Prevention and Control||269|
|Part III||Conclusions and Recommendations|
|10||Conclusions and Recommendations||305|
|Appendixes B||Committee and Staff Biographies||332|