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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.


Education

There 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