Guidelines for poison control
II. Technical guidance - 2. Information services
Organization and operation
The roles and functions of a poison information centre are briefly described in Section I of these guidelines. This section aims to provide more detailed guidance, principally on the establishment and operation of new centres, but also on the improvement of existing centres. It is additionally concerned with the location, facilities, and equipment of such centres and their staffing. Certain financial aspects are also considered.
The effective functioning of a poison information centre depends on the availability of an adequate volume of evaluated data to furnish a basis for the advice given. Two categories of data are collected: those derived from various external sources, including other centres, as well as scientific journals, textbooks, reports, and data sheets; and those obtained in the course of the centre's information work and its follow-up of reported poisoning cases.
It is essential for centres to have data on local commercial products, including pharmaceuticals, as well as on natural toxins produced by local poisonous plants and poisonous and venomous animals. Centres may be expected to identify tablets, capsules, plants, fungi, and insects and other animals. Each centre uses data culled from the various sources in compiling its own documentation for use by the staff of the centre. This documentation enables staff to provide information that is appropriate for the particular enquirer and adapted to local and national conditions. It is thus unique to the centre and essential for the information service that the centre provides.
Centres should establish a mechanism for obtaining access to adequate data on commercial products from manufacturers and importers; such data should be regularly updated and its confidentiality protected. A system of rapid access to data on foreign products is also essential. Information on the composition, packaging, and form of each product must be available and sufficiently detailed to allow the product to be identified, its toxicity evaluated, and its long-term effects assessed.
The documentation prepared by the centre itself on aspects of poisoning by chemicals and products, including evaluation of toxicity, symptoms, and treatment, is of particular importance. Past experience of poisoning cases involving specific chemicals and products plays an important role in this. Data on clinical cases, covering circumstances of poisoning, relevant medical histories, and the full evolution of each case, should be included in this documentation. Data on enquiries to the centre, as well as clinical data, should be systematically collected: they provide unique toxicological information that can be extremely valuable in diagnosis and treatment. To be of maximum value, case data must be fully recorded and followed up. Exchanges of such data between poison information centres, both nationally and internationally, could greatly enhance the effectiveness of the services they provide. A standard format for reporting case data and a mechanism for their collection and analysis are essential (see Annex 5).
Centres should also collect (and regularly update) information on health and other relevant resources and facilities in the region or country. This information should cover services that provide diagnosis and treatment, including specialized treatment facilities, such as dialysis units, hyperbaric oxygen chambers, and clinical toxicology services; analytical facilities and the types of analyses they provide; facilities for emergency transport of patients; antidotes and their availability; and other medical and non-medical services with related areas of responsibility.
A poison information centre should have its own library, which could be associated with a university or medical library. Certain books and publications should be accessible at all times at the centre itself; others could be kept at a local medical library but must be immediately accessible. Section 9 lists a selection of the books and journals that may provide library support for a poison information centre.
Poison information centres would benefit greatly from more efficient collection, storage, retrieval, and analysis of the data they require. Computerization is one tool for this purpose, and most established centres have their own computers. The IPCS has developed a computerized information package, known as IPCS INTOX, to help centres in developing their own poison information systems. A summary description of the package is given in Annex 1.
Planning a poison information centre
Identification of the principal toxic risks in the local community helps in determining the activities on which the efforts of a poison information centre should initially be concentrated (e.g. poisoning by pesticides). Available facilities should be reviewed to allow the selection of locations that best meet the criteria outlined in these guidelines. However, it must be stressed that primary prerequisites for the success of a centre are enthusiasm and interest in human toxicology on the part of a group of health care professionals who recognize the problem of poisoning in their country and are committed to dealing with it.
During the planning of a poison information centre, the following questions should be carefully considered:
*To whom will the service be offered initially, e.g. the medical profession only, the public, veterinarians? Will it be a 24-hours-a-day service from the outset? How will it be expanded subsequently? How will its existence be advertised to the user population?
*What are the initial and subsequent staffing requirements? How will the centre contact and recruit the necessary expertise?
*Are the telephone and other communication systems adequate?
*How will the centre collect the full range of data needed to operate the information service?
*How will the reliability, accuracy, and usefulness of the data be evaluated?
*How will the data be compiled, recorded, and stored for rapid retrieval?
*How will the data be managed and updated? Who will have access to what type of data, and who will have the authority to modify data files?
Before a centre becomes operational it is also necessary to:
*obtain certain essential literature (see section 9);
*provide basic training for the staff who will work in the centre
*print forms (in the local language) for collecting information on local commercial products and for recording enquiries to the centre, with provision for follow-up of calls and cases (see Section 8); and
*on the basis of local information, begin compiling files on the chemicals used in local commercial products, including pharmaceuticals, on local natural toxins, and on relevant medical and analytical services available in the country (see below and Section 8).
Operating a poison information centre
Once a poison information centre becomes operational, i.e. is able to offer an emergency response service, it should function around the clock. In the initial period, before the centre is fully staffed, the service may, at certain times, rely on the assistance of established emergency or intensive care services.
For ethical and commercial reasons, much of the information handled by poison information centres, notably that relating to manufactured products and to patients, must be considered as confidential. Responsibility for the correct handling of such information rests essentially with the medical director and eventually with the other staff of the centre, particularly the information specialists who need the information on an emergency basis.
Rapid identification of the poisons or types of poison involved in an emergency is one of a centre's main tasks. The constitution, origin, uses, and toxicity of the pharmaceuticals, chemicals, plants, or animals involved need to be identified immediately to permit the appropriate action to be taken.
Information on commercial products
Most existing poison information centres began by organizing card indexes of basic information on each of the toxic substances or natural toxins used or occurring in the area or country concerned. Although this type of information can now be stored in rapidly accessible computer files, the use of card indexes may still be recommended in a newly established centre for the initial identification of poisons. A computerized system can be added later, and the card index system should therefore contain as much information as is needed, recorded in such a way that it can later be transferred to a computerized system. The recommended format for collecting and storing information on commercial products for use in the IPCS INTOX Package is given in Annex 4.
The card index or computer file should contain entries on all commercial products, such as pharmaceuticals, household products, and pesticides, commonly used in the country concerned. Although files from other (e.g. neighbouring) countries may be useful, every poison information centre will have to organize and maintain its own files. Information for these may be extracted from local pharmacopoeias and government registries, or obtained from pharmaceutical firms, manufacturers of household products, importers of chemicals, etc.
A similar card index or computerized file system should be organized for natural toxins, poisonous plants, and poisonous and venomous animals.
Information on enquiries
Systematically collected data on enquiries form an essential part of the database at a centre. They must cover not merely the enquiries that pertain to clinical cases but every kind of enquiry received at the centre, including toxicological consultations registered by the clinical services.
Standardized recording of enquiries, including those relating to clinical cases, will allow the centre to:
*maintain its own clinical and other data registry
*implement toxicovigilance activities
*support epidemiological and statistical studies
*perform self-audit and continuously evaluate the quality and efficiency of its services
*back up its clinical and legal responsibilities
*validate new techniques of patient management
*provide data for scientific reports
*exchange information with other poison information centres
*contribute to the fund of knowledge on human toxicology.
Computer facilities for recording data on enquiries and cases offer enormous advantages, and the IPCS INTOX package provides a framework for this purpose. Further work is needed on, inter alia, the classification of agents involved in poisoning, the standardization of analytical data, and the harmonization of severity grading of case data; much is being done at present by IPCS in collaboration with poison centres and experienced toxicologists. The format used in the IPCS INTOX Package for recording communications is given in Annex 5.
All poison information centres should prepare annual reports of their activities; a suggested layout for an annual report for a poison information centre is given in Annex 6. This layout provides a comprehensive format, which should be adapted to local circumstances.
Location, facilities, and equipment
General criteria for the location of a poison information centre are given in Section 1 of these guidelines, but the final choice of location will depend on local circumstances. Certain conditions, however, should be respected, namely that:
*the centre is regarded as neutral and independent, and security for all the information stored at the centre is ensured;
*there is rapid and ready communication with other organizations concerned with poisoning, particularly clinical and analytical services;
*access to the centre within the building in which it is located is easy, but restricted for unauthorized persons; and
*the centre is centrally situated within the geographical and demographic area it serves.
The poison information centre should ideally be located within, or closely associated with, a hospital. Location within a hospital has the advantage of providing ready access to a network of medical disciplines that will support and enhance the work of the centre, enabling staff to deepen their knowledge of the clinical aspects of poisoning. If also located within a university, the centre will have easier access to, among other things, libraries, research facilities, and educational activities. Location within a public health institute or ministry permits more activities relating to prevention of poisoning and a closer relationship with decision-making authorities, but it is still essential for the medical staff of a centre to be involved in the care of poisoned patients, and for the information service to operate round the clock.
To some extent, the location may also be determined by the number of enquiries received. For example, if more than 5000 emergencies are registered each year, a full-time staff will be required to provide a 24-hours-a-day service, and the centre should then be an independent facility, though preferably situated in a hospital. However, some centres are run effectively from other locations. If fewer than 5000 calls are received annually, outside support may be required to maintain a 24-hour service. In this case also, the centre may be located in a hospital but should be situated where regular hospital staff, notably from emergency and intensive care wards, are available to assist in maintaining the service.
A poison information centre should be accommodated in suitable rooms or working areas, equipped with basic furniture (desks, tables, chairs) and such other facilities as are essential for its principal functions. Additionally it should have immediate access to the relevant literature and other sources of information.
The rooms should be large enough to permit the efficient storage and retrieval of documents and the holding of necessary meetings. One room should be allocated to the "answering" service and should contain the telephones assigned to it, plus the basic files, protocols, and books needed by the information specialists and physicians on duty. An area should be set aside as a library where scientific work can be undertaken. Another area is required for working groups and staff or other meetings; this should be at least large enough to allow the assembly of all the staff of the centre, together with a number of advisers or visitors.
Staff on duty should have a private area providing the basic facilities for personal hygiene and rest. Food and drink should also be available, as well as vehicle parking space outside the building.
The medical director should have an office or suitable private area for specific work, interviews, and consultations; similar facilities should be available to other staff receiving patients. A separate area should also be assigned for administrative and secretarial work. As a centre develops new functions, additional space may be required and the location should therefore allow for this future expansion. Experience has demonstrated that, as more information is gathered and new activities or responsibilities assumed, bigger working areas rapidly become necessary.
The minimum furniture needed for a new centre consists of desks and chairs, a large work table, lockable filing cabinets, and bookshelves. As the service develops and the working area grows, further appropriate office and library furniture should be provided. When the service starts functioning on a round-the-clock basis, the medical toxicologists and information specialists on duty must have a private area with suitable furniture and an adequate degree of comfort. It may also be necessary to provide a bed for rest between duty periods. Optimally, there could be specially designed work stations incorporating computer terminals where appropriate.
It is particularly important that a poison information centre should have equipment for fast and reliable communication, and for the storage and retrieval of information.
Communication with enquirers must be through reliable telephones reserved for the purpose and covering the whole area served by the centre. Two telephones are a minimum. In some countries the poison information centre is automatically connected with the emergency telephone services, and all calls concerned with toxicological emergencies are directed straight to the centre. The emergency number of the centre should be easy to remember and accessible from all telephones in the region served by the centre. In developing regions of the world, the radio telephone can be useful in reaching distant areas and remote populations. Other rapid methods of communication include the telex and, for documents, the fax, now considered a "must" at most centres. Electronic mailing systems (e-mail) are now being established at some centres. Fast and reliable communication will be valuable not only for the information service but also for the necessary contacts with other centres and access to international databanks. These systems must be well maintained and financially supported by the appropriate authorities or government ministry. The importance of worldwide communication networks for toxicology has been recognized: ideally, the centre should be equipped with the most practical advanced communication system appropriate to the country and to the centre's functions.
The storage of case records, files, and documentation requires, at the least, sufficient bookshelves and filing cabinets to permit systematic collection and easy retrieval. A lockable section should be available for confidential data.
With the development of the service, additional space, furniture, and storage facilities should be made available for the growing collection of books, published material, and files. If circumstances permit, automated systems may replace manual storage, retrieval, and processing systems, and computers must consequently be recognized as important items of equipment for a poison information centre. A microfiche system may also be a useful means of storing documentation.
A poison centre often has to stock antidotes and other substances used in the treatment of poisonings and therefore requires a refrigerator; a lockable cabinet for storing pharmaceutical agents should be provided.
From the outset, a centre should be adequately equipped with typewriters, a word processor with a good quality printer, and photocopying equipment or other suitable means of reproducing documents. The role of a centre in education and training may require it to have its own slide, overhead, and video projection equipment.
A poison information centre should be headed by a director experienced in toxicology and have sufficient personnel to perform the duties of the centre on a 24-hours-a-day, 7-days-a-week basis. The director is wholly responsible for the operation of the centre and should ideally be employed on a full-time basis. He or she should have personal leadership qualities, together with the ability to supervise other staff and maintain good relations with colleagues and other collaborators in the poison control programme. The director should also be able to promote research, raise funds, and undertake the further development of the information service. The medical functions of the centre must be the responsibility of a medical toxicologist. It may also be desirable to have an administrative director responsible for the financial, administrative, and other non-medical aspects of the centre. In addition, full-time - and possibly also part-time - medical toxicologists, poison information specialists, and administrative and support staff are required. Ultimately, centres also need advisers in various medical and non-medical fields, few of whom would normally be on the staff of the centre at the outset. The work of the centre may eventually call for the services of a number of full-time or part-time experts in particular fields such as psychiatry and veterinary medicine.
In Part I of these guidelines it was pointed out that a fully operational centre, providing a round-the-clock service and adequate medical advice, requires a minimum of three full-time medical toxicologists (or the part-time equivalent) and a sufficient number of poison information specialists to ensure at least one person being on duty at any given time. The frequency of enquiries is likely to vary during the course of the day, and it may be necessary to have additional staff on duty at certain times. In this respect, patterns vary throughout the world, and it is up to the individual centre to ensure that its service is adequate for local needs. In practice, at least 6-8 dedicated, trained, full-time poison information specialists are required: this allows for coverage of staff absences for illness, holidays, and professional training.
The medical toxicologist
Medical toxicology is the discipline concerned with the harmful effects of chemicals, including natural substances, on humans, although its scope is broader than simply the clinical aspects of the subject. A medical toxicologist is a qualified physician with several years' experience in the treatment of cases of poisoning and a grounding in such areas as emergency medicine, paediatrics, public health, internal medicine, intensive care, and forensic medicine. Clinical experience in occupational diseases and in diseases caused by pollutants and other chemicals of environmental origin is particularly relevant. Experience in clinical toxicology is essential, and experience in toxicological research is also valuable.
The medical toxicologist may provide expert advice to national decision-making bodies, and is often responsible for training at hospitals and medical faculties, and takes part in the multidisciplinary teaching of toxicology at university level. He or she must keep abreast of the latest developments in all areas of the discipline, including analytical and experimental toxicology.
In the specific field of information, the medical toxicologist must be able to organize and compile a comprehensive dossier on poisons and their effects, based on the available material and personal experience, to train junior toxicologists and the centre's information specialists in collecting and interpreting data, and to give appropriate information in response to enquiries.
It is particularly important for medical toxicologists to undertake the systematic collection and evaluation of clinical observations, as these constitute a major source of information for the poison information centre.
The medical director of a poison information centre should be the most experienced of its medical toxicologists and the best equipped to take responsibility for medical decisions, treatment protocols, and the promotion of research.
The poison information specialist
For the purpose of these guidelines, the personnel directly in charge of the round-the-clock response to enquiries are termed poison information specialists. They must be appropriately trained and able to carry out the basic functions of a poison centre, with the support of a medical toxicologist, preferably a clinician treating poison victims. They should be able to give information to all types of enquirer on the basis of duly evaluated data available at the centre and in accordance with agreed patient management protocols. In cases where information is not available at the centre, they should know how it may be obtained. They must also know when to consult a medical toxicologist or adviser in a special area and should be able to record details of enquiries, cases, or consultations, using a standardized method. In many situations, poison information specialists will help evaluate the data used at the centre. With additional qualifications or experience in information management and computing, they can play a useful role in the organization and management of records kept at the centre.
Poison information specialists may be drawn from many different disciplines, including various branches of medicine, pharmacy, nursing, chemistry, biology, and veterinary science. In each case, training for the specialized work of a poison information centre is essential and should be a continuing process so that they all remain abreast of new developments in toxicology. Information specialists should have the opportunity to participate in appropriate scientific meetings in their own countries and elsewhere. Training should lead to an officially recognized certificate or other qualification: there is a need for universally recognized qualifications in this field.
All members of the information team should take part in the different activities of the centre, e.g. answering enquiries, preparing documentation and reports, operating computer programs, and making regular searches of the literature. Regular discussions among the team on interesting cases and various toxicological problems should be encouraged as a means of making each member aware of new developments and promoting a harmonized approach to poisoning and patient management. Periodic meetings among poison information centres within a country, or from the various countries of a region, should also be encouraged in order to discuss similar topics.
The widespread use of veterinary drugs and the addition of chemicals to animal feedstuffs, unless carried out under veterinary supervision, can lead to contamination of human food. The effects of toxic substances on animals are often unique, and their diagnosis and appropriate management require the expertise of trained veterinarians. Furthermore, cases of exposure of animals to environmental chemicals may provide early warning of the potential exposure of humans. It would be highly desirable for poison information centres to have access to specialist veterinary knowledge in order to be able to recognize and respond to problems of animal poisoning as well as to advise on the risks of human exposure to drugs used for animals.
Administrative and support staff
A centre should have at least one secretary and, if possible, clerical staff to assist in the establishment, maintenance, and updating of the information system. Provision should be made for the maintenance and cleaning of equipment and facilities at the centre; this is often the responsibility of the administration of the building where the centre is located.
The administrative staff of a poison information centre should be qualified to manage and supervise its financial resources, equipment needs, and operational requirements, as well as dealing with routine personnel matters. Ideally, there should be a senior administrator or administrative director in charge of all these activities, with suitable support staff and clearly defined responsibilities that do not overlap with those of the medical director.
If a centre has its own library it will require a librarian or an information specialist/documentalist, or both.
Advisers in special areas
When a poison information centre is being established, a variety of specialist help and advice is essential. This may be medical or non-medical and may come from independent experts or from representatives of specialized organizations and local agencies. As the centre acquires more experience and the scope and volume of its work expand, it may become necessary to employ extra staff with some of the various kinds of expertise indicated below, on a part-time or full-time basis.
Specialists collaborating with the centre should be able to provide, whenever necessary, specific information on subjects within their recognized fields of expertise. The toxicology-related areas where the information might be needed will depend on local circumstances. Advice from the medical profession may be required in such areas as public health, psychiatry, occupational medicine, paediatrics, nephrology, teratology, anaesthesiology, veterinary medicine, pharmacy, epidemiology, and environmental health. Consultation with representatives of medical associations and government or local medical organizations may be of value whenever specific problems arise. In non-medical areas, advice might be needed from specialists in agronomy, botany, zoology, herpetology, entomology, mycology, ecology, statistics, computer sciences, industry, engineering, law, and information technology and other areas of information management.
A close relationship should be established, once those specialists able and willing to collaborate with the centre have been identified. An agreement should be made as to what is expected of the specialists, and how and when advice is to be provided to the centre. No special training is required for these collaborators, but they should be introduced to the work of the centre and the way it functions. Periodic joint scientific meetings and activities may be very helpful in cementing the relationships between the centre and its special advisers, who may also help in training the staff of the centre in their specific areas of competence.
Development of human resources
The evolution of the poison information centre will depend on local circumstances, needs, and resources. Ideally, there should be career opportunities for all the staff of a centre, each of whom should have the chance of additional training and advancement within his or her own area of competence. Contacts with other agencies dealing with various aspects of the prevention and treatment of poisoning should be stimulated both within the country and abroad. Where appropriate, professional staff should be encouraged to undertake relevant research and contribute to the literature.
Since poison information centres can be considered as part of the public health service, government resources are the most appropriate source of financial support. However, each centre must remain neutral, independent, and preferably autonomous in order to carry out its functions effectively, and these conditions must be respected, whatever the principal source of financing.
Governments should recognize the cost-effectiveness of the service provided by poison information centres to the community, and therefore make every effort to sustain their financial support. It may be difficult for a centre to produce direct evidence of its cost- effectiveness, but it should be stressed that:
*it discourages the excessive use of medical resources
*it reduces the adverse effects of poisoning on health, as well as mortality from poisoning
*it helps to reduce the risks of occupational poisoning.
Other sources of funding may be acceptable, if they are available and if the autonomy of the centre is guaranteed. Social groups in the community, fund-raising campaigns, philanthropic groups, and associations of industry and commerce may all be sources of support. Funds for specific projects received from national and international organizations concerned with chemical safety may be very useful for investigating areas of joint interest. Private funding initiatives have proved to be effective in many countries and should not be discouraged, particularly in the case of new services.
It is an important principle that information should be provided free of charge, at least in an emergency. However, some payment to the centre may be appropriate when special reports or expertise are requested by private institutions or individuals.
Although the bulk of a centre's budget will be devoted to salaries, it should be remembered that adequate funding for the maintenance of up-to-date information is essential. Significant portions of the budget should also be devoted to the operation and maintenance of equipment, for example the telephones, telex, fax, photocopying, and computer systems, as well as to the development of appropriate educational material.
Poison information centres are important sources of information on human toxicology; in particular, they may be able to signal the approach of new toxicological hazards. They also have enormous scope for broadening the scientific database on human toxicology through regional and international cooperation. Their research function should be recognized and encouraged by the relevant authorities.