Research Article
Evaluation of poison information services provided by a new poison information center Shobha Churi, Lovin Abraham, M. Ramesh, M. G. Narahari1
ABSTRACT Aim: The aim of this study is to assess the nature and quality of services provided by poison information center established at a tertiary-care teaching hospital, Mysore. Settings and Design: This was a prospective observational study. Materials and Methods: The poison information center was officially established in September 2010 and began its functioning thereafter. The center is equipped with required resources and facility (e.g., text books, Poisindex, Drugdex, toll free telephone service, internet and online services) to provide poison information services. The poison information services provided by the center were recorded in documentation forms. The documentation form consists of numerous sections to collect information on: (a) Type of population (children, adult, elderly or pregnant) (b) poisoning agents (c) route of exposure (d) type of poisoning (intentional, accidental or environmental) (e) demographic details of patient (age, gender and bodyweight) (f) enquirer details (background, place of call and mode of request) (g) category and purpose of query and (h) details of provided service (information provided, mode of provision, time taken to provide information and references consulted). The nature and quality of poison information services provided was assessed using a quality assessment checklist developed in accordance with DSE/World Health Organization guidelines. Statistical Analysis: Chi-Square test (χ2). Results: A total of 419 queries were received by the center. A majority (n = 333; 79.5%) of the queries were asked by the doctors to provide optimal care (n = 400; 95.5%). Most of the queries were received during ward rounds (n = 201; 48.0%), followed by direct access (n = 147; 35.1%). The poison information services were predominantly provided through verbal communication (n = 352; 84.0%). Upon receipt of queries, the required service was provided immediately (n = 103; 24.6%) or within 10-20 min (n = 296; 70.6%). The queries were mainly related to intentional poisoning (n = 258; 64.5%), followed by accidental poisoning (n = 142; 35.5%). The most common poisoning agents were medicines (n = 124; 31.0%). The service provided was graded as “Excellent” for the majority of queries (n = 360; 86%; P < 0.001), followed by “Very Good” (n = 50; 12%) and “Good” (n = 9; 2%). Conclusion: The poison information center provided requested services in a skillful, efficient and evidence-based manner to meet the needs of the requestor. The enquiries and information provided is documented in a clear and systematic manner.
Department of Pharmacy Practice, JSS College of Pharmacy, 1 Department of Medicine, JSS Medical College and Hospital, JSS University, Mysore, Karnataka, India Received: 14-11-2012 Revised: 23-02-2013 Accepted: 30-06-2013 Correspondence to: Asst. Prof. Shobha Churi, E-mail: [email protected]
KEY WORDS: Evaluation, poison information center, poison information services, quality Access this article online Website: www.ijp-online.com
Quick Response Code:
DOI: 10.4103/0253-7613.117781
496 Indian Journal of Pharmacology | October 2013 | Vol 45 | Issue 5
Introduction Every year, approximately half a million people die worldwide due to poisoning.[1-3] According to the World Health Organization (WHO) report,[4] pesticide poisoning is the most common poisoning in developing countries and the incidence rate has doubled in the past 10 years (more than 50% of the total cases world-wide). Although the trends of poisoning are different
Churi, et al.: Evaluation of a new poison information center
across India due to different demographic, socio-economical and risk factors,[3] the most common poisoning agents in India are also pesticides, followed by sedatives, drugs, chemicals, alcohols, plant toxins and household cleansing agents.[5,6] It is noteworthy that approximately nine million synthetic and natural chemicals are available in India.[2] Unfortunately, majority of them are widely distributed across India and easily available for purchase due to lack of stringent regulatory laws, thereby influencing the incidence of poisoning.[1,3,7-9] Recognizing the problem of poisoning and the need for awareness and specialized facilities to deal with it, poison information centers have been established in some parts of India.[1-3] A poison information center is a specialized unit that advises on or assists with, the prevention, diagnosis and management of poisoning.[10-12] For the management of poisoning cases, poison information centers are a ready source of help as they can provide authentic information and guidelines for first aid and treatment of emergencies related to toxic exposures.[10,11] A global study undertaken during the period 1984-1986 indicated that while most of the developed countries had wellestablished facilities for poison control, this was rarely the case in developing countries.[11] Ideally, the poison information centers should provide information in a timely and excellent manner.[12] It has been found that fulfilling these goals improves the quality of patient care and help reduce the poisoning incidences.[13,14] The services provided by a poison information center not only help reduce the morbidity and mortality caused by poisoning, but also help reduce future accidental poisoning.[8,12,13,15] Poison information services are highly costeffective as timely information can reduce the health-care expenditures by reducing unnecessary admissions and/or preventing prolonged hospitalization.[8,12,13,16] Regional poison information center help understand local risk factors, provide critical information in a more efficient manner and create better awareness using a local language.[8,14-16] We recently established a new poison information center at a tertiary-care teaching hospital, Mysore. This center has been receiving queries continuously and has been providing vital information to both general public and medical professionals. In our previous studies,[7,9,17] we established patterns of poisoning in Mysore region, appropriate scales to prospectively predict the severity of poisoning and the relationship between the predicted severity and actual clinical outcome. As it is important to maintain high quality services, we assessed the nature and quality of services provided by the new poison information center in the current study. The results of the current study may help to improve the quality of services provided by our center. Subjects and Methods
poisoning in either gender, irrespective of age and the poison information services provided during the 14-month period were included in the study. Queries related to poisoning in animals were excluded from the study. Handling of a Poison Information Query The queries pertaining to poisoning in humans received by the center were handled according to a modified systematic approach.[8,14,15,18] Briefly, the query was received by a clinical pharmacist and requested information was provided to the enquirer by adopting a systematic approach as described in the following steps: Step 1 Receive and collect enquirer demographics: Poison-related queries were received either over a telephonic conversation or directly from an enquirer at the center. The complete details were collected and his/her identification was established. Any additional information relevant to the query that would help provide a good response was also collected. Step 2 Collect background information: The basic information related to poisoning and victim such as age and/or weight of victim, substance/product name, route of contact (oral, inhalation, dermal, ocular), quantity and/or strength involved, time since exposure, patient’s condition, treatment received and health status of the patient including medication history, allergies, relevant pre-existing conditions was collected. Step 3 Assessment of the condition: The urgency of the situation was then assessed and categorized as emergency, serious and not serious. The likelihood of toxicity associated with the exposed toxins was assessed based on the nature of substance, type of exposure and quantity consumed. Step 4 Develop and conduct a search strategy. In this step, a list of appropriate resources was prepared and prioritized based on the probability of locating the desired information. Readily accessible resources at the center are databases such as Poisindex (Thomson Reuters Micromedex® 1.0 and Micromedex® 2.0), Hypertox, Intox and poison management protocols. Step 5 Evaluate and provide the information. Comprehensive information related to options was collected. A suitable response was prepared after critically evaluating the collected information. The response or feedback was provided in the form of verbal conversation or written document or printed materials or through fax or e-mail as required. The suggested line of management was according to the current evidence available and was patient specific.
Study Site A prospective observational study was conducted over a period of 14 months (January 2011 to February 2012) at the poison information center established at Department of Clinical Pharmacy, JSS College of Pharmacy, located at the tertiary care teaching hospital (JSS Hospital, Mysore).
Step 6 Conduct follow-up: Follow-up of the case is vital to assess the outcome and to know if the management of poisoning requires further information. Personal visits were allowed when the victim was admitted to the hospital. In other cases, the follow-up was made through telephonic enquiry and e-mail.
Study Criteria About 40 patients were admitted per month, due to intentional or accidental poisoning. All queries pertaining to
Step 7 Documentation: The details related to enquirer, query and the response were documented in an appropriate format. A proper Indian Journal of Pharmacology | October 2013 | Vol 45 | Issue 5 497
Churi, et al.: Evaluation of a new poison information center
documentation not only helps while dealing with similar future queries, but is also needed to justify the professional value and for protective measure against legal liability. Step 8 Maintain confidentiality: All issues related to query was kept confidential due to socio-legal reasons. The details of enquirer were not disclosed to family members, health-care professionals and to other unknown people. Assessment of Nature and Extent of Poison Information Services The nature of services was assessed by analyzing the details collected on background information, type of population, poisoning and poisoning agent. Received queries were classified as given in Table 1 and corresponding abundance was determined by calculating the percentage value (number of queries of particular category/total number of queries ×100). Development of Quality Assessment Checklist A quality assessment checklist [Annexure I] was prepared in accordance with DSE/WHO seminar guidelines.[14,15,18] The quality of the services provided by the center was assessed by conducting a survey using a quality assessment checklist. This checklist consisted of 10 questions with three options/choices (Yes/No/Not Applicable [NA]) for each question. The option “Yes” and “NA” represent 1 point; while “No” represent 0 point. The grading was performed on the basis of scores obtained as follows: Excellent (score = 10), Very good (score = 8-9), Good (score = 5-7), Poor (score = 3-4) and Unacceptable (score = 1-2). The questionnaire was prepared by considering the overall details collected on different aspects including: (a) Details of enquirer, patient and poisonous substance, (b) urgency of the situation, (c) resources, (d) analysis, (e) appropriateness of the information and (f) time taken to provide information. Documentation in an appropriate format and follow-up details were also verified to assess the quality of services. Constitution of Quality Assessment Panel and Development of Guidelines to Assess the Quality of Poison Information Service A quality assessment panel was constituted to assess the quality of poison information services. The panel included 2 casualty medical officers (JSS Hospital, Mysore), 1 physician (JSS Medical College and Hospital, Mysore), 1 paediatrician (JSS Medical College and Hospital, Mysore) and 1 academic clinical pharmacist (JSS College of Pharmacy, Mysore). The panel then formulated standard guidelines to assess the quality of poison information services provided by the centre. On monthly basis, randomly selected two-third of the queries answered were assessed for the quality of service provided using the quality assessment panel. Assessment of the Quality of Poison Information Services The quality of services was assessed by the constituted panel using the quality assessment checklist and adopting the quality assessment guidelines. Briefly, the quality assessment panel, with a quorum of at least three members, assembled in the 1st week of every month to evaluate the quality of services provided in the previous month. Two-third of the answered queries were randomly selected for the assessment of quality of services. The quality of services was assessed on the basis of information 498 Indian Journal of Pharmacology | October 2013 | Vol 45 | Issue 5
Table 1: Classification of poison information queries based on background information and relative abundance Background information
Sub category
Enquirer’s status
Doctor Other health-care professionals General public Health care facility Work place Residence Ward rounds Direct access Telephone e-mail Management Identification Antidote Toxic effects Toxico-kinetics Toxico-dynamics Range of toxicity To know the contents Better patient care Update knowledge Poisindex Text books Database of brand names Standard treatment protocols Others (websites and published articles) Verbal Written Printed e-mail Immediately Within 10-20 min Within 1 h Within 2-4 h Within a day
Place from query asked
Mode of receiving queries
Category of queries*
Purpose of query References consulted#
Mode of provision
Time taken to provide information
Queries (total queries=419) n (%) 333 (79.5) 60 (14.3) 26 (6.2) 375 (89.5) 26 (6.2) 18 (4.3) 201 (48.0) 147 (35.1) 68 (16.2) 03 (0.7) 241 (57.5) 85 (20.2) 46 (11.0) 24 (5.7) 03 (0.7) 03 (0.7) 27 (6.5) 20 (4.8) 400 (95.5) 19 (4.5) 286 (68.2) 78 (18.6) 65 (15.5) 136 (32.5) 67 (16.0) 352 (84.0) 25 (5.9) 40 (9.5) 02 (0.5) 103 (24.6) 296 (70.6) 20 (4.8) 00 (0.0) 00 (0.0)
*Queries were asked regarding more than one category, #More than one references were consulted for certain queries
collected on: (a) Sufficient information related to enquirer, patient and poisonous substance (b) appropriateness of urgency of situation (proper assessment of urgency of the situation) (c) appropriateness of references/resources used to retrieve the information (d) quality of gathered information (critical assessment of gathered information prior to communication) (e) satisfaction of enquirer’s need (f) promptness of service (provision of service within specified duration) (g) quality of documentation of provided service (proper documentation) and (h) promptness in follow-up (if required). On the basis of fulfilment of these features, the panel graded each of the
Churi, et al.: Evaluation of a new poison information center
Table 2: Classification of poison information queries according to poisoning agents and relative abundance Type of poisoning agent
Queries n (%)
Medicines House hold products Pesticides Bites/sting Unknown Total
124 (29.6) 114 (27.3) 105 (25.0) 39 (9.3) 18 (4.3) *400 (95.5)
*Queries asked for update knowledge (4.5%) were excluded
poison information queries reviewed in the quality assessment checklist by consensus and approval by the members. Statistical Analysis The statistical significance of the services was analyzed using percentage value and Chi-Square statistical test using the IBM® statistical package for the social sciences version 20.0. The P value was set at 0.001 for computing the significance of services provided. Results The results of poisoning related queries are mentioned in Tables 1 and 2. During the study period (January 2011 to February 2012), the poison information center received 419 queries. Among them, a majority (n = 400; 95.5%; P < 0.001) of queries were related to optimal patient care, followed by knowledge update (n = 19; 4.5%). Queries predominantly came from doctors (n = 333; 79.5%; P < 0.001), followed by other health-care professionals (n = 60; 14.3%) and the general public (n = 26; 6.2%). The origin of queries was in the following order: Healthcare facility (n = 375; 89.5%; P < 0.001) followed by workplace of the enquirers (n = 26; 6.2%), followed by their residence (n = 18; 4.3%). Most of the queries were received during ward rounds (n = 201; 48.0%), followed by direct queries (n = 147; 35.1%). Rest of the queries was received through telephone or e-mail. Notably, 241 queries (57.5%; P < 0.001) were related to the management of the poisoning. Mode of communication involved in providing service was chiefly verbal (n = 352; 84.0%; P < 0.001). In some instances, the information was provided in the form of printed materials, written information and through e-mail. An effort was made to provide the required information in a timely and efficient manner. For instance, 296 (70.6%) queries were answered within 10-20 min. Importantly 103 (24.6%) queries were answered immediately depending upon the urgency, importance and availability of resources. However, relatively longer time taken for some queries was attributed to the time consumed for extensive literature search in complicated cases. The center mainly used Poisindex (n = 286; 68.2%) as a key resource to obtain information on management of poisoning. Poisindex is the largest and most complete source for quickly identifying, managing and treating toxicological exposures. The database of brand names was also compiled by the center and used for the identification of certain poisoning agents. Other resources such as published articles and websites were
also used to gather required information. Typically, multiple resources were used to gather and provide comprehensive information. Among the queries related to optimal patient care (n = 400), significant (P < 0.001) queries (258; 64.5%) were due to intentional poisoning, followed by accidental poisoning (n = 142; 35.5%). The most commonly detected poisons were medicines (n = 124; 31.0%), followed by household products (n = 114; 27.2%) and pesticides (n = 105; 26.2%) [Table 2]. However, there was no statistically significant difference between all the three poisoning agents (P > 0.001). The quality of poison information services was assessed using a quality assessment checklist (see Annexure I) developed in accordance with the DSE/WHO seminar guidelines. The service provided was graded as “Excellent” for a majority of queries (n = 360; 86%; P < 0.001), followed by “Very Good” (n = 50; 12%) and “Good” (n = 9; 2%). Further, evaluation showed that the poison information service was provided in a timely and excellent manner [Table 1]. Discussion A new poison information center was established at JSS Hospital, Mysore, with an aim to provide critical information during the management of poisoning incidences. With the help of timely and vital information, optimal care can be provided during the crisis. As a result, morbidity and mortality associated with poisoning can be reduced. However, performance and usefulness of poison or drug information center depends on the ability to respond and gather information on the enquiry and requestor in an efficient manner. It also depends on the ability to locate, analyze and deliver the information required in a skillful, efficient and evidence-based manner to meet the needs of the requestor and document enquiries and information given in a clear and systematic manner.[8,12-15,17,19] Hence, we evaluated the quality of services provided by the center. The results of the current study indicated that services were provided in a timely and excellent manner. Importantly, the services provided helped the doctors to provide optimal patient care and update their knowledge. The new poison information center organizes educational programs in and around the Mysore district to create awareness about poisoning substances and appropriate preventive measures. The results of current and previous[7-9,17] studies indicate that new poison information center is providing critical services as envisaged for the center. The findings of this study were in agreement with study conducted by Sam et al.[14] For instance, Sam et al. similarly evaluated the quality of poison information services and reported that service was similarly provided in a timely and excellent manner.[14] Further, a majority of queries in their study were also received during ward rounds. Therefore, the results of the current and Sam et al. studies point to the importance of poison information service during routine and follow-up ward rounds. Importantly, the efficiency of poison information center reported in the current study was comparable to those of a well-established poison information center.[15] For example, Asiri et al.[15] evaluated the quality of services provided at a collegebased center located at King Saud University, Saudi Arabia, were it was found that the majority of queries were replied to within Indian Journal of Pharmacology | October 2013 | Vol 45 | Issue 5 499
Churi, et al.: Evaluation of a new poison information center
ANNEXURE I Quality Assessment Checklist Poison Information Centre Department of Clinical Pharmacy, JSS Hospital, JSS University Mahathma Gandhi Road, Agrahara, Mysore - 570 004 Poison Information Services Quality Assessment Checklist 1.
Was appropriate background information of the enquirer obtained? Yes No N/A
2.
Were appropriate patient demographics and other relevant details collected? Yes No N/A
3.
Were the details of the poisonous substance obtained? Yes No N/A
4.
Was the urgency of the situation assessed properly? Yes No N/A
5.
Was appropriate references/resources used to retrieve the information? Yes No N/A
6.
Was the information provided critically analyzed prior to communication? Yes No N/A
7.
Was the information given relevant to the enquirer’s need? Yes No N/A
8.
Was the information provided to enquirer within a specified period of time? Yes No N/A
9.
Was proper documentation of the service provided done? Yes No N/A
10. Was patient follow-up (if any) conducted? Yes No N/A Poison Information Service Grading Scale: (Excellent: 10, Very Good: 8-9, Good: 5-7, Poor: 3-4, Unacceptable: 1-2) Note: Checked Yes carries 1 point and No carries 0 point. Not applicable question carries 1 point. Reference No: Date of documentation of Query: Total Score: Grade: Remarks: Date of Audit: Name of the Auditors: Signature of the Auditors:
10-20 min of the enquiry. Further, the key resources used by our poison information center (e.g., Poisindex, Hypertox, Intox and poison management protocols) to provide services were also used by well-established poison information centers in other countries.[15,16] This indicates that poison information center evaluated in the current study is well-equipped to provide the requisite information. Conclusions The poison information center at JSS Hospital, Mysore, 500 Indian Journal of Pharmacology | October 2013 | Vol 45 | Issue 5
has been continuously receiving poison related queries from both health care professionals and the general public. The center has been recording queries and related information in a clear and systematic manner. The service has been provided in a skillful, efficient and evidence-based manner. The quality of service provided to a majority of queries was graded as “Excellent”. The center has also been involved creating awareness about its services in rural and urban areas. The awareness program includes educating people on safe storage and use of poisons and) importance of first-aid techniques in poisoning. Further studies are also underway to evaluate the influence of awareness and educational intervention programs on the incidence of poisoning and optimal patient care. Acknowledgment Authors are thankful to the JSS University, Principal, JSS College of Pharmacy, Head, Department of Pharmacy Practice, JSS College of Pharmacy, Medical superintendent, JSS Medical College Hospital for their support during the study. The authors are also indebted to quality assessment panel members.
References 1. Churi S, Harsha CS, Ramesh M. Patterns of poison information queries received by a newly established south Indian poison information center. Asian J Pharm Clin Res 2012;5:79-82. 2. Harish D, Chavali K, Singh A, Kumar A. Recent advances in the management of poisoning cases. J Indian Acad Forensic Med 2011;33:74-9. 3. Sharma BR, Harish D, Sharma V, Vij K. Poisoning in northern India: Changing trends, causes and prevention thereof. Med Sci Law 2002;42:251-7. 4. WHO Guidelines for poison control, 2011. Available from: http://www.who.int/ ipcs/publications/training/poisons/guidelines_poisoncontrol/en/index1.html. [Cited on 2011 Jan 29]. 5. Dash S, Mohanty M, Mohanty S. Socio-demographic profile of poisoning cases. J Indian Acad Forensic Med 2005;27:133-8. 6. Singh D, Jit I, Tyagi S. Changing trends in acute poisoning in Chandigarh zone: A 25-year autopsy experience from a tertiary care hospital in northern India. Am J Forensic Med Pathol 1999;20:203-10. 7. Churi S, Bhakta K, Madhan R. Organophosphate poisoning: Prediction of severity and outcome by Glasgow Coma Scale, poisoning severity score, Acute Physiology and Chronic Health Evaluation II score, and Simplified Acute Physiology Score II. J Emerg Nurs 2012;38:493-5. 8. Churi S, Madhan R, Parthasarathi G. Poison information center — An overview of its significance, organization and functioning. Indian J Pharm Pract 2011;4:14-20. 9. Churi S, Ramesh M, Bhakta K, Chris J. Prospective assessment of patterns, severity and clinical outcome of Indian poisoning incidents. Chem Pharm Bull (Tokyo) 2012;60:859-64. 10. Setting up of poison information center, 2011. Available from: http://www.gujhealth. gov.in/pdf/poison-information-centre.pdf. [Cited on 2011 Apr 26]. 11. Poison Centres-World Health Organization, 2011. Available from: http://www.who. int/ipcs/poisons/centre/en/index.html. [Cited on 2011 Apr 30]. 12. Lall SB, Peshin SS. Role and functions of Poisons Information Centre. Indian J Pediatr 1997;64:443-9. 13. Laborde A. New roles for poison control centres in the developing countries. Toxicology 2004;198:273-7. 14. Sam KG, Rajan MS, Saghir Z, Kumar P, Rao P. Evaluation of poison information services of a clinical pharmacy department in a south Indian tertiary care hospital. J Clin Diagn Res 2009;3:1313-8. 15. Asiri YA, Al-Arifi MN, Al-Sultan MS, Gubara OA. Evaluation of drug and poison information center in Saudi Arabia during the period 2000-2002. Saudi Med J 2007;28:617-9. 16. Ponampalam R. Cost benefits of the Drug and Poison Information Centre in preventing unnecessary hospitalisation: The Singapore experience. Hong Kong J Emerg Med 2010;17:45-53. 17. Jesslin J, Adepu R, Churi S. Assessment of prevalence and mortality incidences
Churi, et al.: Evaluation of a new poison information center
due to poisoning in a South Indian tertiary care teaching hospital. Indian J Pharm Sci 2010;72:587-91. 18. Barlett G, Miller J, Baler L. Evaluating the quality and effectiveness of a drug information center, Berlin. DSE/WHO Seminar on Drug Information Centers, 1997. 19. Abdi SA, Churi S, Ravi Kumar YS. Study of drug utilization pattern of antihyperglycemic agents in a South Indian tertiary care teaching hospital. Indian
J Pharmacol 2012;44:210-4. Cite this article as: Churi S, Abraham L, Ramesh M, Narahari MG. Evaluation of poison information services provided by a new poison information center. Indian J Pharmacol 2013;45:496-501. Source of Support: Nil, Conflict of Interest: None declared.
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Evaluation of poison information services provided by a new poison information center Shobha Churi, Lovin Abraham, M. Ramesh, M. G. Narahari1
ABSTRACT Aim: The aim of this study is to assess the nature and quality of services provided by poison information center established at a tertiary-care teaching hospital, Mysore. Settings and Design: This was a prospective observational study. Materials and Methods: The poison information center was officially established in September 2010 and began its functioning thereafter. The center is equipped with required resources and facility (e.g., text books, Poisindex, Drugdex, toll free telephone service, internet and online services) to provide poison information services. The poison information services provided by the center were recorded in documentation forms. The documentation form consists of numerous sections to collect information on: (a) Type of population (children, adult, elderly or pregnant) (b) poisoning agents (c) route of exposure (d) type of poisoning (intentional, accidental or environmental) (e) demographic details of patient (age, gender and bodyweight) (f) enquirer details (background, place of call and mode of request) (g) category and purpose of query and (h) details of provided service (information provided, mode of provision, time taken to provide information and references consulted). The nature and quality of poison information services provided was assessed using a quality assessment checklist developed in accordance with DSE/World Health Organization guidelines. Statistical Analysis: Chi-Square test (χ2). Results: A total of 419 queries were received by the center. A majority (n = 333; 79.5%) of the queries were asked by the doctors to provide optimal care (n = 400; 95.5%). Most of the queries were received during ward rounds (n = 201; 48.0%), followed by direct access (n = 147; 35.1%). The poison information services were predominantly provided through verbal communication (n = 352; 84.0%). Upon receipt of queries, the required service was provided immediately (n = 103; 24.6%) or within 10-20 min (n = 296; 70.6%). The queries were mainly related to intentional poisoning (n = 258; 64.5%), followed by accidental poisoning (n = 142; 35.5%). The most common poisoning agents were medicines (n = 124; 31.0%). The service provided was graded as “Excellent” for the majority of queries (n = 360; 86%; P < 0.001), followed by “Very Good” (n = 50; 12%) and “Good” (n = 9; 2%). Conclusion: The poison information center provided requested services in a skillful, efficient and evidence-based manner to meet the needs of the requestor. The enquiries and information provided is documented in a clear and systematic manner.
Department of Pharmacy Practice, JSS College of Pharmacy, 1 Department of Medicine, JSS Medical College and Hospital, JSS University, Mysore, Karnataka, India Received: 14-11-2012 Revised: 23-02-2013 Accepted: 30-06-2013 Correspondence to: Asst. Prof. Shobha Churi, E-mail: [email protected]
KEY WORDS: Evaluation, poison information center, poison information services, quality Access this article online Website: www.ijp-online.com
Quick Response Code:
DOI: 10.4103/0253-7613.117781
496 Indian Journal of Pharmacology | October 2013 | Vol 45 | Issue 5
Introduction Every year, approximately half a million people die worldwide due to poisoning.[1-3] According to the World Health Organization (WHO) report,[4] pesticide poisoning is the most common poisoning in developing countries and the incidence rate has doubled in the past 10 years (more than 50% of the total cases world-wide). Although the trends of poisoning are different
Churi, et al.: Evaluation of a new poison information center
across India due to different demographic, socio-economical and risk factors,[3] the most common poisoning agents in India are also pesticides, followed by sedatives, drugs, chemicals, alcohols, plant toxins and household cleansing agents.[5,6] It is noteworthy that approximately nine million synthetic and natural chemicals are available in India.[2] Unfortunately, majority of them are widely distributed across India and easily available for purchase due to lack of stringent regulatory laws, thereby influencing the incidence of poisoning.[1,3,7-9] Recognizing the problem of poisoning and the need for awareness and specialized facilities to deal with it, poison information centers have been established in some parts of India.[1-3] A poison information center is a specialized unit that advises on or assists with, the prevention, diagnosis and management of poisoning.[10-12] For the management of poisoning cases, poison information centers are a ready source of help as they can provide authentic information and guidelines for first aid and treatment of emergencies related to toxic exposures.[10,11] A global study undertaken during the period 1984-1986 indicated that while most of the developed countries had wellestablished facilities for poison control, this was rarely the case in developing countries.[11] Ideally, the poison information centers should provide information in a timely and excellent manner.[12] It has been found that fulfilling these goals improves the quality of patient care and help reduce the poisoning incidences.[13,14] The services provided by a poison information center not only help reduce the morbidity and mortality caused by poisoning, but also help reduce future accidental poisoning.[8,12,13,15] Poison information services are highly costeffective as timely information can reduce the health-care expenditures by reducing unnecessary admissions and/or preventing prolonged hospitalization.[8,12,13,16] Regional poison information center help understand local risk factors, provide critical information in a more efficient manner and create better awareness using a local language.[8,14-16] We recently established a new poison information center at a tertiary-care teaching hospital, Mysore. This center has been receiving queries continuously and has been providing vital information to both general public and medical professionals. In our previous studies,[7,9,17] we established patterns of poisoning in Mysore region, appropriate scales to prospectively predict the severity of poisoning and the relationship between the predicted severity and actual clinical outcome. As it is important to maintain high quality services, we assessed the nature and quality of services provided by the new poison information center in the current study. The results of the current study may help to improve the quality of services provided by our center. Subjects and Methods
poisoning in either gender, irrespective of age and the poison information services provided during the 14-month period were included in the study. Queries related to poisoning in animals were excluded from the study. Handling of a Poison Information Query The queries pertaining to poisoning in humans received by the center were handled according to a modified systematic approach.[8,14,15,18] Briefly, the query was received by a clinical pharmacist and requested information was provided to the enquirer by adopting a systematic approach as described in the following steps: Step 1 Receive and collect enquirer demographics: Poison-related queries were received either over a telephonic conversation or directly from an enquirer at the center. The complete details were collected and his/her identification was established. Any additional information relevant to the query that would help provide a good response was also collected. Step 2 Collect background information: The basic information related to poisoning and victim such as age and/or weight of victim, substance/product name, route of contact (oral, inhalation, dermal, ocular), quantity and/or strength involved, time since exposure, patient’s condition, treatment received and health status of the patient including medication history, allergies, relevant pre-existing conditions was collected. Step 3 Assessment of the condition: The urgency of the situation was then assessed and categorized as emergency, serious and not serious. The likelihood of toxicity associated with the exposed toxins was assessed based on the nature of substance, type of exposure and quantity consumed. Step 4 Develop and conduct a search strategy. In this step, a list of appropriate resources was prepared and prioritized based on the probability of locating the desired information. Readily accessible resources at the center are databases such as Poisindex (Thomson Reuters Micromedex® 1.0 and Micromedex® 2.0), Hypertox, Intox and poison management protocols. Step 5 Evaluate and provide the information. Comprehensive information related to options was collected. A suitable response was prepared after critically evaluating the collected information. The response or feedback was provided in the form of verbal conversation or written document or printed materials or through fax or e-mail as required. The suggested line of management was according to the current evidence available and was patient specific.
Study Site A prospective observational study was conducted over a period of 14 months (January 2011 to February 2012) at the poison information center established at Department of Clinical Pharmacy, JSS College of Pharmacy, located at the tertiary care teaching hospital (JSS Hospital, Mysore).
Step 6 Conduct follow-up: Follow-up of the case is vital to assess the outcome and to know if the management of poisoning requires further information. Personal visits were allowed when the victim was admitted to the hospital. In other cases, the follow-up was made through telephonic enquiry and e-mail.
Study Criteria About 40 patients were admitted per month, due to intentional or accidental poisoning. All queries pertaining to
Step 7 Documentation: The details related to enquirer, query and the response were documented in an appropriate format. A proper Indian Journal of Pharmacology | October 2013 | Vol 45 | Issue 5 497
Churi, et al.: Evaluation of a new poison information center
documentation not only helps while dealing with similar future queries, but is also needed to justify the professional value and for protective measure against legal liability. Step 8 Maintain confidentiality: All issues related to query was kept confidential due to socio-legal reasons. The details of enquirer were not disclosed to family members, health-care professionals and to other unknown people. Assessment of Nature and Extent of Poison Information Services The nature of services was assessed by analyzing the details collected on background information, type of population, poisoning and poisoning agent. Received queries were classified as given in Table 1 and corresponding abundance was determined by calculating the percentage value (number of queries of particular category/total number of queries ×100). Development of Quality Assessment Checklist A quality assessment checklist [Annexure I] was prepared in accordance with DSE/WHO seminar guidelines.[14,15,18] The quality of the services provided by the center was assessed by conducting a survey using a quality assessment checklist. This checklist consisted of 10 questions with three options/choices (Yes/No/Not Applicable [NA]) for each question. The option “Yes” and “NA” represent 1 point; while “No” represent 0 point. The grading was performed on the basis of scores obtained as follows: Excellent (score = 10), Very good (score = 8-9), Good (score = 5-7), Poor (score = 3-4) and Unacceptable (score = 1-2). The questionnaire was prepared by considering the overall details collected on different aspects including: (a) Details of enquirer, patient and poisonous substance, (b) urgency of the situation, (c) resources, (d) analysis, (e) appropriateness of the information and (f) time taken to provide information. Documentation in an appropriate format and follow-up details were also verified to assess the quality of services. Constitution of Quality Assessment Panel and Development of Guidelines to Assess the Quality of Poison Information Service A quality assessment panel was constituted to assess the quality of poison information services. The panel included 2 casualty medical officers (JSS Hospital, Mysore), 1 physician (JSS Medical College and Hospital, Mysore), 1 paediatrician (JSS Medical College and Hospital, Mysore) and 1 academic clinical pharmacist (JSS College of Pharmacy, Mysore). The panel then formulated standard guidelines to assess the quality of poison information services provided by the centre. On monthly basis, randomly selected two-third of the queries answered were assessed for the quality of service provided using the quality assessment panel. Assessment of the Quality of Poison Information Services The quality of services was assessed by the constituted panel using the quality assessment checklist and adopting the quality assessment guidelines. Briefly, the quality assessment panel, with a quorum of at least three members, assembled in the 1st week of every month to evaluate the quality of services provided in the previous month. Two-third of the answered queries were randomly selected for the assessment of quality of services. The quality of services was assessed on the basis of information 498 Indian Journal of Pharmacology | October 2013 | Vol 45 | Issue 5
Table 1: Classification of poison information queries based on background information and relative abundance Background information
Sub category
Enquirer’s status
Doctor Other health-care professionals General public Health care facility Work place Residence Ward rounds Direct access Telephone e-mail Management Identification Antidote Toxic effects Toxico-kinetics Toxico-dynamics Range of toxicity To know the contents Better patient care Update knowledge Poisindex Text books Database of brand names Standard treatment protocols Others (websites and published articles) Verbal Written Printed e-mail Immediately Within 10-20 min Within 1 h Within 2-4 h Within a day
Place from query asked
Mode of receiving queries
Category of queries*
Purpose of query References consulted#
Mode of provision
Time taken to provide information
Queries (total queries=419) n (%) 333 (79.5) 60 (14.3) 26 (6.2) 375 (89.5) 26 (6.2) 18 (4.3) 201 (48.0) 147 (35.1) 68 (16.2) 03 (0.7) 241 (57.5) 85 (20.2) 46 (11.0) 24 (5.7) 03 (0.7) 03 (0.7) 27 (6.5) 20 (4.8) 400 (95.5) 19 (4.5) 286 (68.2) 78 (18.6) 65 (15.5) 136 (32.5) 67 (16.0) 352 (84.0) 25 (5.9) 40 (9.5) 02 (0.5) 103 (24.6) 296 (70.6) 20 (4.8) 00 (0.0) 00 (0.0)
*Queries were asked regarding more than one category, #More than one references were consulted for certain queries
collected on: (a) Sufficient information related to enquirer, patient and poisonous substance (b) appropriateness of urgency of situation (proper assessment of urgency of the situation) (c) appropriateness of references/resources used to retrieve the information (d) quality of gathered information (critical assessment of gathered information prior to communication) (e) satisfaction of enquirer’s need (f) promptness of service (provision of service within specified duration) (g) quality of documentation of provided service (proper documentation) and (h) promptness in follow-up (if required). On the basis of fulfilment of these features, the panel graded each of the
Churi, et al.: Evaluation of a new poison information center
Table 2: Classification of poison information queries according to poisoning agents and relative abundance Type of poisoning agent
Queries n (%)
Medicines House hold products Pesticides Bites/sting Unknown Total
124 (29.6) 114 (27.3) 105 (25.0) 39 (9.3) 18 (4.3) *400 (95.5)
*Queries asked for update knowledge (4.5%) were excluded
poison information queries reviewed in the quality assessment checklist by consensus and approval by the members. Statistical Analysis The statistical significance of the services was analyzed using percentage value and Chi-Square statistical test using the IBM® statistical package for the social sciences version 20.0. The P value was set at 0.001 for computing the significance of services provided. Results The results of poisoning related queries are mentioned in Tables 1 and 2. During the study period (January 2011 to February 2012), the poison information center received 419 queries. Among them, a majority (n = 400; 95.5%; P < 0.001) of queries were related to optimal patient care, followed by knowledge update (n = 19; 4.5%). Queries predominantly came from doctors (n = 333; 79.5%; P < 0.001), followed by other health-care professionals (n = 60; 14.3%) and the general public (n = 26; 6.2%). The origin of queries was in the following order: Healthcare facility (n = 375; 89.5%; P < 0.001) followed by workplace of the enquirers (n = 26; 6.2%), followed by their residence (n = 18; 4.3%). Most of the queries were received during ward rounds (n = 201; 48.0%), followed by direct queries (n = 147; 35.1%). Rest of the queries was received through telephone or e-mail. Notably, 241 queries (57.5%; P < 0.001) were related to the management of the poisoning. Mode of communication involved in providing service was chiefly verbal (n = 352; 84.0%; P < 0.001). In some instances, the information was provided in the form of printed materials, written information and through e-mail. An effort was made to provide the required information in a timely and efficient manner. For instance, 296 (70.6%) queries were answered within 10-20 min. Importantly 103 (24.6%) queries were answered immediately depending upon the urgency, importance and availability of resources. However, relatively longer time taken for some queries was attributed to the time consumed for extensive literature search in complicated cases. The center mainly used Poisindex (n = 286; 68.2%) as a key resource to obtain information on management of poisoning. Poisindex is the largest and most complete source for quickly identifying, managing and treating toxicological exposures. The database of brand names was also compiled by the center and used for the identification of certain poisoning agents. Other resources such as published articles and websites were
also used to gather required information. Typically, multiple resources were used to gather and provide comprehensive information. Among the queries related to optimal patient care (n = 400), significant (P < 0.001) queries (258; 64.5%) were due to intentional poisoning, followed by accidental poisoning (n = 142; 35.5%). The most commonly detected poisons were medicines (n = 124; 31.0%), followed by household products (n = 114; 27.2%) and pesticides (n = 105; 26.2%) [Table 2]. However, there was no statistically significant difference between all the three poisoning agents (P > 0.001). The quality of poison information services was assessed using a quality assessment checklist (see Annexure I) developed in accordance with the DSE/WHO seminar guidelines. The service provided was graded as “Excellent” for a majority of queries (n = 360; 86%; P < 0.001), followed by “Very Good” (n = 50; 12%) and “Good” (n = 9; 2%). Further, evaluation showed that the poison information service was provided in a timely and excellent manner [Table 1]. Discussion A new poison information center was established at JSS Hospital, Mysore, with an aim to provide critical information during the management of poisoning incidences. With the help of timely and vital information, optimal care can be provided during the crisis. As a result, morbidity and mortality associated with poisoning can be reduced. However, performance and usefulness of poison or drug information center depends on the ability to respond and gather information on the enquiry and requestor in an efficient manner. It also depends on the ability to locate, analyze and deliver the information required in a skillful, efficient and evidence-based manner to meet the needs of the requestor and document enquiries and information given in a clear and systematic manner.[8,12-15,17,19] Hence, we evaluated the quality of services provided by the center. The results of the current study indicated that services were provided in a timely and excellent manner. Importantly, the services provided helped the doctors to provide optimal patient care and update their knowledge. The new poison information center organizes educational programs in and around the Mysore district to create awareness about poisoning substances and appropriate preventive measures. The results of current and previous[7-9,17] studies indicate that new poison information center is providing critical services as envisaged for the center. The findings of this study were in agreement with study conducted by Sam et al.[14] For instance, Sam et al. similarly evaluated the quality of poison information services and reported that service was similarly provided in a timely and excellent manner.[14] Further, a majority of queries in their study were also received during ward rounds. Therefore, the results of the current and Sam et al. studies point to the importance of poison information service during routine and follow-up ward rounds. Importantly, the efficiency of poison information center reported in the current study was comparable to those of a well-established poison information center.[15] For example, Asiri et al.[15] evaluated the quality of services provided at a collegebased center located at King Saud University, Saudi Arabia, were it was found that the majority of queries were replied to within Indian Journal of Pharmacology | October 2013 | Vol 45 | Issue 5 499
Churi, et al.: Evaluation of a new poison information center
ANNEXURE I Quality Assessment Checklist Poison Information Centre Department of Clinical Pharmacy, JSS Hospital, JSS University Mahathma Gandhi Road, Agrahara, Mysore - 570 004 Poison Information Services Quality Assessment Checklist 1.
Was appropriate background information of the enquirer obtained? Yes No N/A
2.
Were appropriate patient demographics and other relevant details collected? Yes No N/A
3.
Were the details of the poisonous substance obtained? Yes No N/A
4.
Was the urgency of the situation assessed properly? Yes No N/A
5.
Was appropriate references/resources used to retrieve the information? Yes No N/A
6.
Was the information provided critically analyzed prior to communication? Yes No N/A
7.
Was the information given relevant to the enquirer’s need? Yes No N/A
8.
Was the information provided to enquirer within a specified period of time? Yes No N/A
9.
Was proper documentation of the service provided done? Yes No N/A
10. Was patient follow-up (if any) conducted? Yes No N/A Poison Information Service Grading Scale: (Excellent: 10, Very Good: 8-9, Good: 5-7, Poor: 3-4, Unacceptable: 1-2) Note: Checked Yes carries 1 point and No carries 0 point. Not applicable question carries 1 point. Reference No: Date of documentation of Query: Total Score: Grade: Remarks: Date of Audit: Name of the Auditors: Signature of the Auditors:
10-20 min of the enquiry. Further, the key resources used by our poison information center (e.g., Poisindex, Hypertox, Intox and poison management protocols) to provide services were also used by well-established poison information centers in other countries.[15,16] This indicates that poison information center evaluated in the current study is well-equipped to provide the requisite information. Conclusions The poison information center at JSS Hospital, Mysore, 500 Indian Journal of Pharmacology | October 2013 | Vol 45 | Issue 5
has been continuously receiving poison related queries from both health care professionals and the general public. The center has been recording queries and related information in a clear and systematic manner. The service has been provided in a skillful, efficient and evidence-based manner. The quality of service provided to a majority of queries was graded as “Excellent”. The center has also been involved creating awareness about its services in rural and urban areas. The awareness program includes educating people on safe storage and use of poisons and) importance of first-aid techniques in poisoning. Further studies are also underway to evaluate the influence of awareness and educational intervention programs on the incidence of poisoning and optimal patient care. Acknowledgment Authors are thankful to the JSS University, Principal, JSS College of Pharmacy, Head, Department of Pharmacy Practice, JSS College of Pharmacy, Medical superintendent, JSS Medical College Hospital for their support during the study. The authors are also indebted to quality assessment panel members.
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due to poisoning in a South Indian tertiary care teaching hospital. Indian J Pharm Sci 2010;72:587-91. 18. Barlett G, Miller J, Baler L. Evaluating the quality and effectiveness of a drug information center, Berlin. DSE/WHO Seminar on Drug Information Centers, 1997. 19. Abdi SA, Churi S, Ravi Kumar YS. Study of drug utilization pattern of antihyperglycemic agents in a South Indian tertiary care teaching hospital. Indian
J Pharmacol 2012;44:210-4. Cite this article as: Churi S, Abraham L, Ramesh M, Narahari MG. Evaluation of poison information services provided by a new poison information center. Indian J Pharmacol 2013;45:496-501. Source of Support: Nil, Conflict of Interest: None declared.
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