Executive Summary

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.1 Furthermore, we examined how poison control centers function relative to the functions performed by other health

1  

The term toxicologist is a general description of an individual dealing with any aspect of acute or chronic poisonings, and it does not have a specific definition or implication with regard to training or job description. For example, this term may be used to describe individuals whose activities range from molecular biology to epidemiology, as long as they deal in some way with the toxic effects of chemicals. The term clinical toxicologist implies a more clinical orientation, but likewise has no specific definition or implications. Medical toxicologists are physicians with specific training and board certification in the subspecialty of medical toxicology, which focuses on the care of poisoned patients.



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Forging a Poison Prevention and Control System Executive Summary 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.1 Furthermore, we examined how poison control centers function relative to the functions performed by other health 1   The term toxicologist is a general description of an individual dealing with any aspect of acute or chronic poisonings, and it does not have a specific definition or implication with regard to training or job description. For example, this term may be used to describe individuals whose activities range from molecular biology to epidemiology, as long as they deal in some way with the toxic effects of chemicals. The term clinical toxicologist implies a more clinical orientation, but likewise has no specific definition or implications. Medical toxicologists are physicians with specific training and board certification in the subspecialty of medical toxicology, which focuses on the care of poisoned patients.

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Forging a Poison Prevention and Control System BOX ES-1 Committee Charge The Institute of Medicine was asked by the Maternal and Child Health Bureau of the Health Resources and Services Administration 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 to review: The scope of services provided, including consumer telephone consultation, technical assistance, and/or hospital consultation for the care of patients with life-threatening poisonings, and education of the public and professionals; The coordination of poison control centers with other public health, emergency medical, and other emergency services; The strengths and weaknesses of various organizational structures for poison control centers and services, including a consideration of personnel needs; Approaches to providing the financial resources for poison prevention and control services; Methods for assuring consistent, high-quality services, including the certification of centers and methods of evaluation; and Current and future data systems and surveillance needs. The Committee was asked to consider these questions in light of future demographic and population trends, and in the context of the threats of biological and chemical terrorism. care agencies and government organizations at the federal, state, and local levels. Poisoning is a much larger public health problem than has generally been recognized, 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

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Forging a Poison Prevention and Control System 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

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Forging a Poison Prevention and Control System BOX ES-2 Defining Poisoning “All things are poison and not without poison; only the dose makes a thing not a poison” Paracelsus (1493–1541) There is no standard definition of poisoning that is universally accepted and applied in clinical practice, in data collection, and in public health policy settings. Clinical Definition Human poisoning subsumes any toxin-related injury. The injury can be systemic or organ-specific (e.g., neurological injury or hepatotoxicity). The source of the toxin can be a synthetic chemical or a naturally occurring plant, animal, or mineral substance. Thus poisoning can include the toxic effects of a classic toxin (e.g., cyanide), an overdose of a prescription medication (e.g., an antidepressant), an overdose of an over-the-counter preparation (e.g., headache tablets), or a complementary treatment (such as an herbal medicine or dietary supplement). Classification Complexities Disagreement over the classification of certain poisoning events leads to discrepancies in the estimates of poison-related mortality and morbidity; prominent among these disagreements are: Exposures that fall in and out of various classification schemes (e.g., envenomation from a rattlesnake or black widow spider might be grouped with nontoxic bites). Medical misadventure/adverse effects at therapeutic levels; medication responses that are not dose related but idiosyncratic, with or without allergic component. Delayed versus acute toxic effects. Illness from naturally occurring toxins derived from microorganisms (e.g., seafood-related toxins). Toxic effects from ethanol (e.g., rapid ingestion, withdrawal, chronic). Exposure to a potential toxin without a defined clinical effect (as when parents telephone a poison control center about a possible ingestion by their child). The Committee’s Operational Definitions To arrive at reasonable estimates of the magnitude of poisoning, the Committee adopted the definitions used by key federal health agencies and organizations that monitor poisoning in the population (see Chapter 3 for details). Morbidity estimates used definitions from the National Interview Health Survey, National Ambulatory Medical Care Survey, National Hospital Ambulatory Care Survey, National Hospital Discharge Survey, and National Electronic Injury Surveillance Survey. Exposure estimates were derived from the Toxic Exposure Surveillance System. Mortality estimates used the classification of the National Center for Health Statistics.

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Forging a Poison Prevention and Control System 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. BACKGROUND 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 2   The Committee’s higher estimates are based on multiple sources that include but are not limited to those used in Healthy People 2010. In addition, the Committee’s analyses drew on dates between 1997 and 2001, whereas Healthy People 2010 estimates are for 1997.

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Forging a Poison Prevention and Control System 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 com-

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Forging a Poison Prevention and Control System plete “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.3 A regional distribution of such centers would satisfy the need to distribute medical toxicological leadership across the United States to address 3   In 2002, the Presidential Task Force on Citizen Preparedness in the War on Terrorism recommended that poison control centers provide emergency information in the event of a terrorist event involving biological, chemical, or nuclear toxins.

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Forging a Poison Prevention and Control System 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 organiza-

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Forging a Poison Prevention and Control System tions 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. Recommendations 1. All poison control centers should perform a defined set of core activities supported by federal funding that is tied to the provision of these activities. The core activities include: (1) manage telephone-based poison exposure and information calls; (2) prepare and respond to all-hazards emergency needs (especially biological or chemical terrorism or other mass exposure events); (3) capture, analyze, and report exposure data; (4) train poison control center staff, including specialists in poison information and poison information providers; (5) carry out continuous quality improvement; and (6) integrate their services into the public health system. In addition, a subset of poison control centers should train medical toxicologists; this is considered a core activity for only a subset of poison control centers because their involvement is necessary for the certification of this specialty. A subset of poison control centers should also assist in the training of pharmacists through clinical toxicology fellowships that prepare them for poison control center management positions. 2. Poison control centers should collaborate with state and local health departments to develop, disseminate, and evaluate public and professional education activities. Poison control centers alone cannot fulfill the need for public and professional education related to poisoning prevention and treatment and all-hazards response. Public health agencies already have the authorities, networks, and administrative mechanisms to carry out broad educational efforts, as they do for the prevention of other injuries and for other public health campaigns. Coordination of Poison Control Centers with Other Public Health Entities The mission of public health is to assure conditions in which people can be healthy. As noted earlier, meeting the ambitious national objectives for poisoning prevention set by the U.S. Department of Health and Human Services in Healthy People 2010, particularly with the potential

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Forging a Poison Prevention and Control System burden of biological and chemical attacks, requires the combined efforts of public health agencies and the proposed regional system of poison control centers. The public health system, through its Essential Services of Public Health and core functions of assessment, policy development, and assurance, offers a useful framework for providing and coordinating poison prevention services (see Table ES-1). To achieve the ultimate goal of preventing poisonings, as well as to improve the outcomes for those who are poisoned, the Committee envisions the need for a clear, single point of accountability at each level of government. The responsible agencies would assure the accomplishment of all public health core functions or essential services as they relate to TABLE ES-1 Core Functions and Essential Services of Public Health as Applied to Poison Prevention and Control Services Core Functions 10 Essential Services Assessment Collection, assembly, analysis, and distribution of information on the community’s health 1. Monitor health status to identify community problems. 2. Diagnose and investigate health problems and the health hazards in the community. 3. Evaluate the effectiveness, accessibility, and quality of personal and population-based health services. Policy development Development of comprehensive policies based on scientific knowledge and decision making 4. Inform, educate, and empower people about health issues. 5. Mobilize community partnerships to identify and solve health problems. 6. Develop policies and plans that support individual and community health efforts. Assurance Determination of needed personal and communitywide health services, and provision of these services by encouraging action by others, by requiring action by others, or by direct provision 7. Assure a competent public health and personal health care workforce. 8. Enforce laws and regulations that protect health and ensure safety. 9. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. Assessment, policy development, and assurance 10. Research for new insights and innovative solutions to health problems.   SOURCE: Adapted from the IOM report, The Future of Public Health (1988).

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Forging a Poison Prevention and Control System poison prevention and control. This does not mean that the responsible agencies would perform all the functions within their respective agencies. However, they would (1) take responsibility for developing the plan to accomplish the activities needed to ensure that the system is in place, with a set of uniform standards across the country; (2) convene and work with the other agencies, including the existing poison control center network, to implement the plan; and (3) work in partnership to develop a set of performance standards for all components of the system. One possible model for the development of performance measures for a state-federal partnership is the Title V Maternal and Child Health (MCH) Block Grant, which is administered by states, and the federal grants for MCH activi- Examples as Applied to Poison Prevention and Control Services 1. Monitor population frequency of poisonings across the lifespan. Assess outcomes. 2. Assess factors contributing to poisonings. Develop policies and services for primary and secondary prevention. 3. Evaluate public education activities related to poisonings. Continuously review and evaluate poison control center functions and their efficiency and effectiveness. Ensure the availability and accessibility of poison control information to the entire public. 4. Assess and enhance the public’s knowledge about poison impact, prevention, and control. 5. Establish effective communication with community members regarding poisonings. 6. Apply population-based data to policy development for poison prevention and control. 7. Create and maintain a workforce that is competent in poison prevention and control. Educate health professionals on subjects related to poisonings. 8. Develop laws, statutes, and regulations that provide for optimal use of poison control centers and protect individuals in the workplace. 9. Create provisions for high-quality, culturally competent poison control center services. Ensure linkages among all parts of the public health and medical systems with poison control centers. 10. Identify best practices for poison control centers. Contribute to the evidence base for poison prevention and control through the funding and generation of new knowledge.

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Forging a Poison Prevention and Control System ties, which are administered by the MCHB in HRSA. This partnership has been in place for 5 years and has successfully developed and implemented performance criteria and data reporting mechanisms. Recommendations 3. The U.S. Department of Health and Human Services (DHHS) and the states should establish a Poison Prevention and Control System that integrates poison control centers with public health agencies, establishes performance measures, and holds all parties accountable for protecting the public. At the federal level, the Secretary of Health and Human Services should designate the lead agency for this purpose; at the state level, the governor of each state should formally designate the appropriate lead (e.g., injury prevention directors from the public health entity). The Secretary of DHHS should assure integration of the existing regional network of poison control centers with the public health system. The Secretary of DHHS should create a single national repository of legislation, model prevention and education programs, website designs, and best practices material. Technical assistance should be provided for website design, content, navigation, and maintenance, maximizing the individual centers’ identity and contributions. Materials should be evaluated for quality and impact on intended audiences. For maximum effectiveness, their content should reflect the range of cultures and languages in the United States. The governor should assure that relevant all-hazards emergency preparedness and response activities are integrated with the Poison Prevention and Control System. 4. The Centers for Disease Control and Prevention (CDC), working with HRSA and the states, should continue to build an effective infrastructure for all-hazards emergency preparedness, including bioterrorism and chemical terrorism. A specific activity of this effort is to evaluate, through an objective structured review, the use of TESS as a source of case detection to all-hazards surveillance. Strengths and Weaknesses of Poison Control Center Organizational Structures Early in its information gathering, the Committee decided that the existing data should be adequate to address the questions raised by HRSA about the organization and financing of the centers. Unfortunately, as the analysis progressed, we found that no data on service quality and outcomes had been systematically collected by the centers and that data on local variations in salaries and rent were not readily available. As a result,

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Forging a Poison Prevention and Control System the Committee’s analysis provided only preliminary findings. The Committee found a wide range of service-delivery models, organizational structures, and financing arrangements among poison control centers that successfully deliver core services. Although an earlier study conducted on six poison control centers suggested possible economies of scale for service areas of 2 million people or more, the Committee found little conclusive evidence, in its own analysis, that economies of scale operate with respect to size of population served and poison control center costs. Costs were best predicted by variables related to staffing patterns and wage rates rather than hardware expenses, population served, or funding source. More complete data are needed to further explore this important concern. The Committee’s qualitative analysis of 10 poison control centers indicated that the more efficient centers had lower staff turnover rates with fewer concerns about salaries and were more likely to (1) participate in partnerships or joint ventures in the community, (2) have written strategic plans specific to the poison control center, and (3) be organizationally affiliated with a private institution. Furthermore, the more efficient centers were less likely to cite problems related to complex reporting and accountability and problems of balancing core poison control functions with other activities such as research and bioterrorism response and preparedness. It is important to note that the analyses were based solely on population served, cost per human exposure call, and penetrance. The existing data are insufficient for the development of either contractual specifications or performance measures for a new Poison Prevention and Control System. The Committee suggests new data-gathering efforts to obtain original financial and performance data from existing poison control centers. These data are needed to guide future public funding of core activities. Recommendation 5. HRSA should commission a systematic management review focusing on organizational determinants of cost, quality, and staffing of poison control centers as the foundation for the future funding of this program. This analysis should include the following elements: The development of new indicators of quality and impact of poison control center services. The implications of different organizational structures and funding accountabilities on service quality and impact. The role of center size and governance in poison control center service quality and impact.

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Forging a Poison Prevention and Control System The impact of regional differences on poison control center operational cost. How staffing patterns, recruitment, and retention of poison control center staff affect cost, quality, and impact of poison control centers. An economic evaluation of poison control centers to determine whether economies of scale exist among them. Financial Support for the Poison Prevention and Control System: Poison Control Centers and State and Local Infrastructures Poison control centers are currently funded by a patchwork of sources (including federal, state, institutional, and private) that are subject to budget cuts and changing priorities every year. Across the states there are 29 separate funding sources. Some examples include federal and state Medicaid programs, federal block grants, federal grants, state line-item appropriation, state-funded universities, telephone surcharges, private hospitals, and private donations. As financial pressures on state governments and health systems have risen, the willingness of traditional funders to continue to provide revenues has diminished, leaving many centers facing great uncertainty, budget pressures, and cutbacks. In 2001, AAPCC reported $104 million in total funding for poison control centers. In a separate analysis, the Committee estimated a similar amount by multiplying the cost per human exposure call4 by call volume. The Committee concludes that the most effective approach to stabilization is through federal funding of approximately $100 million to support the core activities. This funding could reduce or replace the support for core activities provided by many of the current funding sources; however, it would not reduce the need for state and local funding to support non-core services. Recommendation 6. Congress should amend the current Poison Control Center Enhancement and Awareness Act to provide sufficient funding to support the proposed Poison Prevention and Control System with its national network of regional poison control centers. Support for the core activities at the current level of service is estimated to require more than $100 million annually. Extension of services to include the growing all-hazards emergency needs (especially biological or chemical terrorism) and enhancements 4   Cost per human exposure call represents all poison control center expenses divided by the number of human exposure calls.

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Forging a Poison Prevention and Control System to current surveillance and data collection activities will require additional support and should be supplemented as appropriate to such mandates. The funding could be channeled either through a direct federal grant or a federal-state matching process. Performance measures for poison control center services must be specified and monitored by the funding agencies involved. Separate funding will be required to support activities performed at the federal and state levels. In addition to the funds required by each poison control center to implement the core activities, the Committee estimates an amount roughly on the magnitude of $30 million to assure that all the essential services of public health related to poisoning are accomplished. This estimate includes approximately $10 million in the form of $200,000 grants to each state to support a poison prevention coordinator’s office whose responsibilities would include coordination of public education efforts and a plan for their evaluation and $20 million for federal-level activities, including (1) development and maintenance of quality assurance and improvement mechanisms for every component of the Poison Prevention and Control System; (2) training activities for health providers outside the poison control centers who require training in toxicology, such as emergency department workers and emergency medical technicians; (3) a clearinghouse for primary prevention materials and resources; and (4) research and the translation of research and evaluation studies into best practices and regulatory changes. Federal estimates are based on similar public health programs funded by the CDC and HRSA. Recommendation 7. Congress should amend existing public health legislation to fund a state and local infrastructure to support an integrated Poison Prevention and Control System. The Committee at this time is not able to provide a precise estimate of the required level of support for such a federal and state program. The Committee recommends that the Secretary of Health and Human Services should develop a budget proposal to support the costs of training, research, data archiving and reporting, quality assurance, and public education (including state-level coordination of prevention education and the creation of a central repository of best model programs). This amount is in addition to the $100 million needed to support poison control core services. Assure High-Quality Poison Control Center Services Certification of poison control centers is currently the responsibility of AAPCC, and the centers are required to join this organization to become

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Forging a Poison Prevention and Control System certified. A more accepted model for certification of health care professionals or programs is for it to be the responsibility of an independent agency, rather than an organization in which the applicants are paying members. (For example, medical toxicologists are certified by a board that is a member of the American Board of Medical Specialties rather than by a toxicology organization.) With the continued development of poison control centers and their increased integration into the public health system, alternative certification processes will offer advantages over the current system, including greater independence of the process from the participants, wider input from the health care community, and wider recognition of the skills and contributions of poison control centers and their personnel. Recommendation 8. A fully external, independent body should be responsible for certification of poison control centers and specialists in poison information. This body should be separate from the professional organizations representing them. National Data System and Surveillance Needs A Uniform Definition of Poisoning Among the most important functions of the Poison Prevention and Control System will be the collection and provision of poison exposure and surveillance data to the nation’s health authorities. The Committee found many barriers to the effective operation of a comprehensive data and surveillance system and to the provision and utilization of the information by agencies at the federal, state, and local levels. The steps to ameliorate this situation are complex, but there is a pressing need for change. The Committee recommends that these be addressed at the same time that the legislative, financing, and organizational reforms are being implemented. Recommendation 9. The Secretary of Health and Human Services should instruct key agencies to convene an expert panel to develop a definition of poisoning that can be used in surveillance activities (including the Toxic Exposure Surveillance System) and ongoing data collection studies. Furthermore: The Secretary should ask the World Health Organization to review and reform the International Classification of Diseases codes for poisoning,

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Forging a Poison Prevention and Control System thereby addressing the discrepancies and complexities identified in the current classification. The Secretary should require agencies that sponsor existing surveillance and data collection instruments to use a common definition of poisoning that allows comparability across data collection efforts. The National Center for Health Statistics (NCHS) should review the methodology of its existing surveys to maximize the value of their survey data for poison prevention and control. Other agencies collecting health-related data at the federal level outside NCHS, and at the state level, should enhance their surveys or surveillance data systems to better gather and interpret data related to poisoning injury and risk factors. Privacy Barriers to Data Collection New patient protections provided by the Health Insurance Portability and Accountability Act (HIPAA) and state privacy regulations have placed substantial limitations on sharing health care data. This situation is exacerbated by the fact that there are many misconceptions among health care professionals regarding the conditions under which such data are available. Recommendation 10. DHHS should undertake a targeted education effort to improve health provider awareness of poisoning data collection as it relates to the Health Insurance Portability and Accountability Act (HIPAA) and state privacy regulations to mitigate their unintended chilling effect on poison control center consultation, including follow-up. DHHS should review and resolve the negative impact of HIPAA and state privacy regulations on poison control center functions, including toxicology consultations and outcomes evaluation. Availability of TESS Data The Toxic Exposure Surveillance System is a proprietary data and surveillance system owned by AAPCC. Using funding from CDC, AAPCC has recently developed a capability to provide real-time surveillance through TESS based on input from the poison control centers. The Committee recognizes that this system was established and has been significantly strengthened through the initiative of AAPCC. However, there is now enough evidence to suggest that a private system cannot meet the national need for timely data in this area. Despite federal funding, the

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Forging a Poison Prevention and Control System computer code for TESS is owned by a private company, further complicating its use and distribution. Recommendation 11. The Director of the Centers for Disease Control and Prevention should ensure that exposure surveillance data generated by the poison control centers and currently reported in the Toxic Exposure Surveillance System are available to all appropriate local, state, and federal public health units and to the poison control centers on a “real-time” basis at no additional cost to these users. These data should also be publicly accessible with oversight mechanisms and privacy guarantees and at a cost consistent with other major public use systems such as those currently managed by the National Center for Health Statistics. Research Needs The Committee made an attempt, within the constraints of the available literature and data systems, to document the magnitude of the poisoning problem and its cost, in terms of health care outcomes, to the nation. We concluded that despite limitations in the data, poisoning is a far greater problem than has been generally recognized and deserves a higher level of scrutiny and support. The Committee recommends a baseline assessment of the magnitude and cost of poisoning. Furthermore, the Committee found a dearth of research on poisoning and poison control center operations and encourages funding of research in this area. Recommendation 12. Federally funded research should be provided for (1) studies on the epidemiology of poisoning, (2) the prevention and treatment of poisoning and drug overdose, (3) health services access and delivery, (4) strategies to improve regulations and facilitate researchers’ input into regulatory procedures, and (5) the cost efficiency of the new Poison Prevention and Control System on population-based outcomes for general and specific poisonings. CDC should take the lead in marshalling the relevant data pertaining to the epidemiology of poisoning. It should produce a comprehensive report estimating the national incidence of poisoning morbidity and mortality, exploiting its existing data sources. Within the centers, the National Center for Injury Prevention and Control (NCIPC) could lead this effort, coordinating data needs with NCHS. Data sources should include TESS, the National Health Interview Survey, the National Electronic Injury Sur-

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Forging a Poison Prevention and Control System veillance System, the Drug Abuse Warning Network, MedWatch, and others. The Agency for Healthcare Research and Quality (AHRQ) and CDC should be directed to undertake a rigorous economic analysis of the overall direct and indirect health care costs of poisoning and drug overdose. The Secretary of Health and Human Services should encourage funding by appropriate agencies, such as CDC and the Consumer Product Safety Commission, to ensure the needed flow of information from toxicology researchers in poison control centers on prevention problems and strategies to regulators from toxicology researchers in poison control centers and to encourage the study and development of new regulatory strategies and initiatives to reduce poisonings. Researchers should be funded through grants from appropriate institutes such as the National Institutes of Health, the National Library of Medicine, AHRQ, and CDC/NCIPC, to study prevention and treatment of poisonings and drug overdose, health service access and delivery, and the cost efficiency and clinical impact of the Poison Prevention and Control System.

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