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Center for Poison Treatment Facility Assessment Guidelines
Preamble
Background
The concept of regional toxicology treatment centers (RTTCs) and the original RTTC Facility Assessment Guidelines were first developed by the Acute and Intensive Care Section of the American Academy of Clinical Toxicology (AACT). Subsequently, the American College of Medical Toxicology (ACMT) has renamed RTTCs as centers for poison treatment (CPTs) and has revised and endorsed the Facility Assessment Guidelines.
Statements of Purpose
The goals of a CPT are to achieve excellence in medical care, teaching and research in medical toxicology while minimizing unnecessary cost. CPTs will enhance patient care through a systematized, multi-disciplinary approach. An essential difference between a CPT and another major medical center is the dedicated leadership by expert specialists in medical toxicology. The importance of this dedicated leadership has been shown by the trauma center system in the US. A “critical mass” of victims of severe or unusual poisonings is essential to achieve excellence in clinical care, training and research. Higher quality clinical training and research will expand the knowledge base in medical toxicology. CPTs that serve as regional referral centers should publicly report and summarize their activities at least annually. CPTs are not intended to compete with regional poison information centers or poison control centers but to work with them to enhance the regional poison care system.
CPT Facility Assessment Guidelines outline the preparations necessary to achieve the goals and objectives. Proper preparation requires a philosophical and financial commitment by the host medical center. These preparations include recruitment a qualified director and toxicology attending staff, a stockpile of recommended antidotes with appropriate staff staff training in their use, and strong support from critical ancillary services such as the Psychiatry Department and the Toxicology Laboratory.
The Facility Assessment Guidelines define reasonable expectations of a CPT for local Emergency Medicine Service (EMS) providers, referring physicians and regional poison information center staff. Understanding and acceptance by these groups are crucial to the success of CPTs. These guidelines will be periodically reviewed by ACMT and revised when appropriate.
Introduction
A center for poison treatment (CPT) offers comprehensive care for victims of severe or unusual poisonings. All medical activities of the CPT shall be under the control and supervision of a qualified medical director. A CPT may be comprised of more than one medical center. CPTs should meet the following general guidelines:
1. The sponsoring medical facility must demonstrate a commitment to providing high quality medical care to poisoned patients. This commitment must be both philosophical and financial and include but is not limited to:
- Dedicated Leadership by Expert Specialists in Medical Toxicology.
- Proper organization and staffing of the Medical Toxicology service.
- Availability of inpatient bed space appropriate for the patient's severity.
- Essential medical equipment.
- Timely laboratory analysis.
- Adequate types and amounts of antidotes.
- Timely and expert psychiatric evaluation and support.
2. The CPT should develop or adopt acute care protocols, provide acute psychiatric consultation, offer post discharge follow-up, perform quality improvement (QI) activities, periodically report activities, perform research and provide regional poison oriented medical education. The details of these programs must be delineated in written policies and procedures.
3. The CPT should work closely with the regional poison information (control) center (RPIC) in providing poison consultations to health care professionals. The CPT and RPIC should attempt to identify special regional needs that would require additional resources.
4. The CPT should submit to periodic review or audit if required by governmental or national professional organizations.
5. The CPT should develop interhospital transfer guidelines and agreements with referring hospitals.
6. The CPT should work closely the regional EMS system to optimize prehospital (PHC) care and transport of poisoned patients to appropriate health care facilities.
7. The CPT should declare its medical catchment areas (geographic referral base), which could consist of multiple EMS regions and may cross state lines.
The following sections will be discussed in more detail: Target Patient Population, Organization, Medical Staff, Facilities, Capabilities, Quality Improvement, Research, Education, Data Collection & Reporting.
Target Patient Population
Patients most likely to benefit from the specialized expertise or resources of CPTs are those at greatest risk of significant morbidity or mortality, or who need prolonged intensive care. Generally, severe or unusual types of poisoning are appropriate for referral to CPTs. The presence of comorbidity factors such as extremes of age or serious underlying medical problems may upgrade a routine poisoning to a severe rating. Examples of special resources that may only be available at the CPT include the expertise of specialists in medical toxicology, special laboratory tests, antidotes or poison treatments (hyperbaric oxygen, hemodialysis, hemoperfusion or emergency cardiopulmonary bypass).
CPTs desiring PHC triage should propose PHC Tox Triage Guidelines to their regional EMS Directors. For interhospital transfers, the decision to transfer and the determination of the appropriate transportation mode are the responsibility of the referring physician made in consultation with the accepting physician toxicologist. The staff of the CPT or the regional poison information center (RPIC) may be consulted when uncertainty exists as to the appropriateness of triage or transfer.
Organization
- Medical Director
Responsible for clinical operations, quality assurance, and clinical protocols.
- Medical Toxicology Service
Provides inpatient admission and/or consultation services.
- Hospital Administration
Develop a regional plan to delineate the relationship of the CPT to regional hospitals.
- Agreements
The relationship to other medical departments and essential services must be documented in the policy and procedure manual. These departments and services should at least include the regional poison information center, regional hazardous materials team, nephrology, neurology, pulmonary, psychiatry, pediatrics, intensive care medicine, toxicology laboratory, pharmacy, regional EMS system and local mycologists, botanists and herpetologists.
- Policy And Procedure Manual
Maintained by the medical toxicology service.
Medical Staff
- Medical Toxicology Staff
1. Medical Director
The Medical
Director must demonstrate expertise and special interest in the field of medical
toxicology. The Medical director must be a physician and board certified in
medical toxicology.
2. Attending Physicians
Attending physicians on the
medical toxicology service should be board certified in medical toxicology or
certified in clinical pharmacology, emergency medicine, family medicine,
internal medicine, pediatrics, or occupational medicine with demonstrated
expertise and special interest in medical toxicology as evidenced by patient
care, publications, research and meeting attendance.
- Other Medical Staff
The following requirements may be fulfilled by
senior resident physicians with special competence in the care of patients with
poisoning/drug emergencies as judged by the Medical Director of the Medical
Toxicology service. These residents must be capable of initiating measures
directed toward stabilizing the patient and beginning the patient management
process. Attending staff specialists are to be on-call and promptly available
for emergency consultation.
- In-Hospital 24 Hours a Day
Anesthesiology/Anesthetist
Emergency
Medicine
Intensivist
- On-Call and Promptly Available
Anesthesiology
Cardiology
Dialysis Staff
General Surgery
GI (Endoscopy)
Hematology
Hyperbaric Medicine
Infectious Disease
Internal Medicine*
Medical Toxicology
Nephrology
Neurology
Obstetrics
Pathology (Analytic Tox)
Pediatrics**
Pediatric
Surgeon**
Psychiatry
Pulmonary Diseases
Radiology
Social Services
Surgery
* adult facilities, **pediatric facilities
Facilities
- Emergency Department
1. Personnel
(1) Designated Medical
Director
(2) Staffed in-house, 24 hours a day, with physicians certified by
or board prepared for the American Board of Emergency Medicine or Osteopathic
Emergency Medicine or American Board of Pediatrics (for pediatric
facilities)
(3) RNs 24 hours a day competent in care of poisoned patients as
evidenced by CEN certification or annual continuing education in medical
toxicology.
2. Equipment - see JCAH criteria for level 1 unit
(1)
Hazardous materials decontamination unit.
3. Protocols for ED management of
the poisoned patients.
- Intensive Care Unit (ICU) Adults and/or Children
1. Designated
Medical Director
Physician competent in resuscitation and initial management
of poisoned patient available in-house 24 hours a day
2. Nurse - Patient
Ratio
Minimum Ratio of 1:3 on each shift and competence in the care of
poisoned patients as evidenced by CCRN certification or annual continuing
education in medical toxicology.
3. Equipment
JCAH criteria for level 1
unit.
Services (available 24
hours/day)
- Hemodialysis / Hemoperfusion
- Radiology
1. CAT scan
2. Fluoroscopy
- Clinical Laboratory
Routine Analysis: Blood, Urine, And Other Body
Fluids
- Blood Bank Services
Typing And Cross Matching
Coagulation
studies
Comprehensive blood bank or access to community central blood bank
and adequate hospital storage facilities
- Microbiology
- Toxicology Laboratory
In-house or by formal agreement
(Appendix A: Suggested Toxicology Laboratory Analyses)
- Pharmacy
Pharmacist available in-house 24 hours a day
Stock of all common antidotes in amounts adequate to meet regional needs.
(Appendix B: Suggested Antidotes)
- Respiratory Care
Qualified respiratory therapists
- Hyperbaric oxygenation
In-house or by formal agreement
- Social Services Department
- Electrophysiology Laboratory
In-house or by formal agreement
1.
EEG
2. EMG
- Psychiatry
There must be capabilities for on site psychiatric care
of suspected suicidal patients.
Inpatient psychiatric care must be available
within the CPT or via transfer.
- Endoscopy
- Surgery
Quality Improvement
- Audit all poison deaths
- Morbidity and mortality review conference
- Case conference, multi-disciplinary
- Medical nursing audit, utilization review, lab review
- Medical records review
Research
The CPT shall
conduct and publish research relating to medical toxicology.
EducationThere shall be
continuing education in medical toxicology for the medical, laboratory, nursing,
and pharmacy staffs of the CPT.
Training in medical toxicology shall be made
available to paramedic, medical and pharmacy students, physicians in training
and medical and nursing staff from other health care facilities in the
region.
Data Collection & Reporting
The CPT shall maintain a database of all patients and report
all cases to their affiliated regional poison information center participating
in the American Association of Poison Control Center's Toxicological Exposure
Surveillance System (AAPCC's TESS).
These guidelines may be revised when appropriate by the American College of
Medical Toxicology.
Revised April 7, 1999
Appendix A - Clinical Laboratory
Testing Guidelines
- Qualitative Tests
Available Within Clinically Relevant
Timespan:
Acetaminophen
Aspirin
Antidepressants
Barbiturates
Benzodiazepines
Opiates
Phencyclidine
Stimulants
- Quantitative Tests
Available Within 2 Hours
Chemistry:
Electrolytes, Glucose, Bun, Cr, Mg, Ca, Phosphate
Coagulation: PT, PTT,
Fibrin Split Products (Or D-D Dimers), Fibrinogen Level, Platelet
Count
Hematology: Blood Count, Complete And Differential
Liver Functions:
SGOT (AST), SGPT (ALT), LDH, Total/Direct Bilirubin
Miscellaneous: Acetone,
Lactate, Osmolality (Freezing Point)
Muscle: Creatine Kinase and
Myoglobin
Oxygenation: ABG, O2 Saturation, COHgb, MeHgb
- Available Within Clinically Relevant Timespan:
Acetaminophen
Aspirin
Barbiturates
Carbamazepine
Carboxyhemoglobin
Cholinesterase,
Serum
Cyanide and Thiocyanate
Digoxin
Ethanol
Ethylene
Glycol
Formate
Heavy Metal: Blood As, Fe, Hg, Pb
Heavy Metal: Urine
As, Hg,
Pb
Isopropanol
Lidocaine
Lithium
Methanol
Methemoglobin
Phenobarbital
Phenytoin
Theophylline
Valproic
acid
Appedix B - Suggested Antidotes
N-Acetyl-Cysteine 20%
Antivenin, Coral
Snake
Antivenin, Crotalidae Polyvalent
Antivenin, Latrodectus
Mactans
Atropine Sulfate
Benztropine Mesylate
Bromocriptine Mesylate
Calcium Disodium Edetate
Calcium Gluconate 10%
Calcium Gluconate Gel
Calcium Chloride 10%
Cathartic
Sorbitol
Mg Or Na Sulfate
Mg Citrate
Charcoal, Activated
Cyanide Antidote Kit
Amyl Nitrite
Sodium Nitrite 3%
Sodium Thiosulfate
Dantrolene Sodium
Deferoxamine Mesylate
Dextrose 50% In Water
Diazepam
Digoxin Immune Fab
Dimercaptosuccinic Acid (DMSA)
Dimercaprol
Diphenhydramine Hydrochloride
Droperidol Or Haloperidol
Ethyl Alcohol 95%
Esmolol
Folic Acid
Fomepizole
Flumazenil
Glucagon
Ipecac Syrup
Lorazepam
Leucovorin
Mannitol 20%
Methylene Blue 1%
Nalmefene
Naloxone Hydrochloride
Nitroprusside, Sodium
D-Penicillamine
Phentolamine
Physostigmine Salicylate
Polyethylene Glycol Electrolyte Lavage Solution
Pralidoxime Chloride
Propranolol
Protamine Sulfate
Pyridoxine Hydrochloride
Sodium Bicarbonate
Starch
Thiamine Hydrochloride
Vitamin K1
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