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Forging a Poison Prevention and Control System 2 Toward a Poison Prevention and Control System In this early chapter of the report, the Committee presents its concept for a Poison Prevention and Control System in order to guide the reader through the analyses presented in subsequent chapters. This approach is necessary because the recommendations for such a system depart considerably from the picture of the current network of poison control centers. The Committee’s argument for a Poison Prevention and Control System follows directly from the charge given to it by the Health Resources and Services Administration/Maternal and Child Health Bureau to develop a “systematic approach to understanding, stabilizing, and providing long-term support for…poison prevention and control services in the United States,” emphasizing “the coordination of poison control centers with other public health, emergency medical and other services.” The Committee views its recommendation to create a Poison Prevention and Control System as central to addressing its charge. The Committee also believed it essential to define at the outset the complex term “poisoning.” Recognizing that there is no single definition agreed upon by all of the relevant professional bodies, we adopted the operational definitions of poisoning used by the agencies that sponsor the various systems that capture and report on poisoning data. For federal datasets capturing morbidity, we used the International Classification of Diseases (ICD)-9 definitions; in the specific case of poisoning mortality, however, the more up-to-date ICD-10 definition of underlying causes of death was used. In the case of exposure calls to poison control centers, we
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Forging a Poison Prevention and Control System adopted the idiosyncratic Toxic Exposure Surveillance System (TESS) definitions, as established by the American Association of Poison Control Centers (AAPCC). THE “SYSTEMS” CHARACTERISTICS OF A POISON PREVENTION AND CONTROL SYSTEM The Committee recognized that comprehensively addressing the issue of poisoning required a “systems approach,” with a broad array of government and nongovernment health agencies, including the poison control centers, working together to achieve the common goal of reducing the incidence and severity of poisonings in the U.S. population. Essential to the system is this shared goal and coordinated activities. As described later (in Chapter 9), the other agencies central to such a system include state and local health departments, emergency medical services units, and federal agencies including the Centers for Disease Control and Prevention, Health Resources and Services Administration, Consumer Product Safety Commission, Food and Drug Administration, and others. Furthermore, the components of the Poison Prevention and Control System must share information freely so that each can assess its contributions and achievements. Shared information, including data from TESS, and feedback and evaluation are at the heart of an effectively functioning system. Later in the report, we make the case that the system needs to be integrated with the broader U.S. public health system. THE ROLE OF POISON CONTROL CENTERS IN A POISON PREVENTION AND CONTROL SYSTEM The Committee concluded that poison control centers are essential components and building blocks of a Poison Prevention and Control System. These centers are on the front line of meeting the needs of the public and the health care community for information and guidance concerning poison exposures. Public satisfaction with this free service appears to be high. The centers have played an important historical role in providing consumer services and have provided data supporting new packaging and labeling regulations. Thus, poison control centers serve a vital public health function, accentuated by the public concerns about exposure to biological and chemical agents of terrorism. In the future, however, poison control centers must be more stable financially, population based, and better integrated and coordinated with other stakeholders involved in the protection of the public from hazardous substances. This conclusion reflects the Committee’s assessment that the current network emerged historically with little planning and no con-
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Forging a Poison Prevention and Control System sistent state or federal agency support. Each center evolved its own unique set of funding sources, depending on the largesse of sponsoring hospitals in some cases, and on idiosyncratic state and local funding sources in other cases. The current size, number, and location of poison control centers reflect this historical evolution that took place without any overall planning or underlying principles of organization. THE CASE FOR REGIONAL POISON CONTROL CENTERS The Committee envisions a system of regional poison control centers across the country, each serving a defined population. Current experience shows that centers can effectively serve regions as small as large metropolitan areas or as large as multiple states. Furthermore, a poison control center may be located within its region or, as is currently the case, may contract to serve regions at some distance from the center. Effective and efficient examples of each type of arrangement currently exist. In cases in which a center contracts from a distance, there must be strong links to state and local public health agencies concerned with poisoning and poisoning prevention. Modern telecommunications technology supports a variety of cooperative arrangements. Such technology also provides the opportunity for one or more centers to assist another center with high call-volume surges or periods of personnel absence or equipment failure. 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 of the expertise in one location, thus 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 center alone cannot meet the entire need. Thus, we concluded that a system of regional centers provided an appropriate balance of size and responsiveness.
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Forging a Poison Prevention and Control System The specific rationale for a regionalized system includes the following elements. Poison control centers must be large enough to sustain an adequately 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 will 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 will 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. Although 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. We believe that the concept of regionalized national poison control centers provides the structural basis for development of a Poison Prevention and Control System. THE CORE FUNCTIONS OF POISON CONTROL CENTERS A fundamental component of this proposal is the specification of the core functions of a poison control center functioning within the Poison Prevention and Control System. Chapter 5 provides more detailed definitions of center core functions. Briefly, the core functions of a regional poison control center will include: Manage telephone-based poison exposure and information calls; Prepare for and respond to all-hazards emergency needs (including biological or chemical terrorism or other mass exposure events) in cooperation with other organizations at local and state levels; Capture, analyze, and report exposure data; Train poison control center staff, including specialists in poison information and poison information providers; Carry out continuous quality improvement;
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Forging a Poison Prevention and Control System Integrate services into the public health system; and Train medical and clinical toxicologists in a subset of poison control centers. CONNECTIONS BETWEEN THE POISON CONTROL CENTERS AND THE BROADER PUBLIC HEALTH SYSTEM The Committee envisions a far stronger set of connections between poison control centers and public health agencies than is currently the case. The rationale for these connections is discussed in detail in Chapter 9 and is based heavily on the concept of a public health system developed by the Institute of Medicine in its landmark report, The Future of Public Health (1988). Furthermore, we believe the Poison Prevention and Control System must be well connected to emergency medical services (EMS) so that emergency medical technicians can be dispatched rapidly where needed, information on exposures and hazards can be shared, and treatment guidelines can be put into place. Finally, the Poison Prevention and Control System will become central to the states’ public health preparedness for bioterrorism or other emergency all-hazards events. Data on poison exposure cannot be kept privately, but rather must be publicly available in real time from the system. The Committee’s conclusions about the collection, ownership, and dissemination of data on poisonings and poison exposure are among the most important aspects of this report. We recognize that TESS was established and strengthened through the initiative of AAPCC, but we believe there is enough evidence now to suggest that a private system cannot meet the national need for timely data in this area. Federal agencies must oversee the collection and management of this system and make the data available to state and local agencies as needed for policy decisions and public health practice. To accomplish these broader goals, the Committee believes that some current poison control center functions will be better carried out by federal, state, or local public health agencies. In this set of activities we include: Primary prevention efforts through public education; Consumer protection through continuous monitoring of poison exposures and translation into regulation of hazardous products; Rapid analysis of exposure data (toxicosurveillance) to detect “outbreaks” and effective use of such data by public health agencies to assure public safety; Program and national policy development and implementation; and Links to EMS and emergency preparedness organizations.
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Forging a Poison Prevention and Control System FEDERAL FUNDING FOR THE CORE SERVICES OF A POISON PREVENTION AND CONTROL SYSTEM The Committee believes that a stronger, better organized, and accountable system for poison prevention and control is in the national interest and must be supported by federal funding and oversight. This will probably require the passage of federal legislation (or the amendment of the current poison control center stabilization legislation) to define specific roles for federal agencies, a funding formula, the definition of contractual obligations, and mechanisms for accountability of the system. There also must be mechanisms in place for effective collaboration and cooperation among the federal agencies with responsibilities in this area and effective linkages to the counterpart state and local agencies. Stakeholders at the federal level include representatives from the Health Resources and Services Administration, Centers for Disease Control and Prevention, Agency for Toxic Substances and Disease Registry, National Center for Health Statistics, U.S. Food and Drug Administration, U.S. Consumer Product Safety Commission, and emergency medical services. THE RESEARCH NEEDS OF A POISON PREVENTION AND CONTROL SYSTEM Finally, the Committee sees a need for a much stronger knowledge base related to poison prevention and control. We have already identified the need to improve the research capacity of the poison control centers themselves. Realizing this goal depends on a federal commitment to fund toxicological, epidemiological, and health services research in this field. Such a commitment must be built into the research mandates of the National Institutes of Health, Centers for Disease Control and Prevention, and Agency for Healthcare Research and Quality. SUMMARY In summary, the proposed Poison Prevention and Control System will be different from what currently exists in several key areas: The component agencies, including the poison control centers, will work cooperatively to reduce the burden of poisoning; The federal legislative base will provide a national mandate and federal core funding; Poison exposure data will be publicly available in real time for agency decision making and for merging with other data sources;
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Forging a Poison Prevention and Control System Poison prevention and control will be integrated into the broader injury prevention and public health systems; The performance of the system will be held accountable; and Primary prevention through public education and hazardous substance regulation will be strengthened.
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