Blue Ridge Poison Center 2017 ANNUAL REPORT

Transcription

1 1 Blue Ridge Poison Center 2017 ANNUAL REPORT March 2018 A Bulletin for Health Care Professionals Who Manage Poisoned Patients BRPC STAFF A MESSAGE FROM OUR DIRECTOR Director Christopher Holstege, MD Nursing Director Beth Mehring, MSN Medical Toxicologists Andy Baer, MD Heather Borek, MD Nathan Charlton, MD Josh King, MD Medical Toxicology Fellows Asaad Alsufyani, MD Justin Rizer, MD Poison Specialists Brenda Beech, RN, CSPI Andre Berkin, BSN, CSPI Jenni Goodwin, BSN, RN Jennifer Horn, BSN, CSPI Sue Kell, Ph.D, M.Ed, CSPI Teresa Kinzie, RN, CCRN, CSPI Christie Lee, RN, CSPI Kathy Mayo, RN, CSPI Scott Wiley, BSN, CSPI Steven Yoder, BSN, CSPI Epidemiologist Saumitra V. Rege, MS, PhD Public Health Educator Kristin Wenger, MT, BS I am pleased to present our 2017 Blue Ridge Poison Center (BRPC) Annual Report. Analysis of the call data from BRPC captures a snapshot of the incidence and severity of poisoning in our area of service within Virginia. This regional data contributes to the statewide findings of the Virginia Department of Health which demonstrates that poisoning consistently is a leading cause of injury hospitalization and injury death. Our team is working collaboratively with numerous professionals across the Commonwealth to help educate the public and professionals of the dangers related to poisonings. Our team, for example, has worked closely with such groups as Lead Safe Virginia, Old Rag Master Naturalists, the Virginia Department of Health, and numerous universities, colleges, local schools, EMS agencies, and healthcare facilities. The BRPC works closely with numerous health providers on how to compassionately care for all poisoned patients using the best medical evidence available. We work to assure appropriate care is administered to toddlers who innocently ingest potentially harmful substances, suicidal patients who take overdoses, employees exposed to industrial chemicals, substance abusers who suffer complications of their addiction, foragers who accidently ingest toxins plants/mushrooms, and those envenomated by one of Virginia s poisonous snakes or spiders. The BRPC consists of a dedicated group of professionals with years of experience in the field of clinical toxicology. Every day our personnel strive for excellence to serve the populace living and working in the BRPC service area. Administrative Specialists Heather Collier Teresa Dorrier View full color version online: Look under Scholarly Work and then click on Annual Report. Christopher P. Holstege, MD Christopher P. Holstege, MD Medical Director, Blue Ridge Poison Center University of Virginia Health System Professor, Departments of Emergency Medicine & Pediatrics University of Virginia School of Medicine

2 2 BRPC Service Area The BRPC serves 54 counties and 20 independent cities of Virginia (Fig. 1). Our region is largely rural, comprised of the Shenandoah Valley, Southwest Virginia, and much of Central Virginia. Many of our counties are designated as a medically underserved area by the Virginia Department of Health. Nearly two and half million Virginians reside in the BRPC service area; it is also the location for 42 hospitals and several psychiatric facilities which use our services. of unwanted substances, pill identification, poisoning prevention, and dosing questions. Additionally, our poison specialists made 21,839 outgoing follow-up calls to check on the health condition of callers with confirmed exposures. Table 1: 2017 Call Volume The BRPC is located in Charlottesville and is affiliated with the University of Virginia Health System. It is certified as a Regional Poison Center by the American Association of Poison Control Centers. Call Volume In 2017 the BRPC received 22,835 calls (Table 1). The majority of calls (64.5%) were attributed to unintentional exposures, while 4,109 (18%) of incoming calls were attributed to intentional exposures including suspected cases of suicide gestures and the intentional misuse or abuse of substances. The BRPC also answered 3,059 information (non-exposure) calls from individuals requesting information on a variety of topics, including but not limited to proper disposal Figure 1: BRPC Service Area

3 3 Exposures: Age and Gender of Patient Children (<20 years) accounted for nearly 57% of all human exposure calls, and those age six years or less accounted for 42% of all exposure calls (Fig. 2). The proportion of exposure calls was slightly greater among females (53%) than males (47%). The sex of the patient was unknown in less than one percent of exposure calls. Figure 2: Patient by Age Group Sources of Poison Exposure In 2017, 60.5% of all exposures were attributed to a pharmaceutical substances, including illicit street drugs. The remaining exposures were attributed to non-drug substances. The top 10 pharmaceuticals and non-pharmaceuticals indicated in an exposure are listed in Table 2. Table 2: Top 10 Pharmaceuticals and Non-Drug Substances Indicated in Exposures NON DRUG SUBSTANCE NUMBER Cosme cs/personal care products 1,649 Cleaning substances (household) 1,560 Foreign bodies/toys/miscellaneous 819 Alcohols 783 Pes cides 686 Plants 506 Bites and envenoma ons 421 Chemicals 371 Hydrocarbons 330 Figure 3: Route of Exposure Arts/cra s/office supplies 287 PHARMACEUTICALS NUMBER Analgesics 2,730 Seda ve/hypno cs/an psycho cs 1,704 An depressants 1,395 Cardiovascular drugs 1,109 An histamines 1,070 Exposure Routes The most frequent route of exposure was through ingestion of substances (80.1%). This covered a wide range of circumstances including accidental swallowing of substances, taking incorrect medicine or doses, and intentional misuse or abuse of substances (Fig. 3). An convulsants 817 S mulants and street drugs 637 Hormones and hormone antagonists 545 Topical prepara ons 544 An microbials 505

4 4 Call site and Management Site Sixty five percent of all exposure calls were from the caller s own residence or another residence. Hospitals, pharmacies, first responders, and other health care facilities (HCF) accounted for 27% of exposure calls. The majority (61.6%) of all human exposure calls were handled on-site or outside of a HCF (Fig. 4). Furthermore, 82.1% of calls originating from a residence, school, restaurant, or workplace were resolved on site. Handling exposure related calls on-site prevents unnecessary visits to healthcare facilities and unnecessary EMS transports, saving time and money in the long run. Table 3 shows the number of calls received from hospitals within the BRPC service area. Figure 4: Management Site Animal Exposure Calls There were 705 animal exposures calls to the BRPC in 2017, accounting for approximately 3.5% of all exposure-related calls. The most frequent exposures among animals were household cleaning substances (6.9%), analgesics (5.4%), and cosmetics/personal care products (4.1%). Table 3: Hospital Calls HOSPITAL CALLS UNIVERSITY OF VIRGINIA 616 CARILION ROANOKE MEMORIAL 384 MARY WASHINGTON 342 LYNCHBURG GENERAL 288 DANVILLE REGIONAL MEDICAL CENTER 220 WINCHESTER MEDICAL CENTER 208 AUGUSTA HEALTH 208 LEWIS GALE Salem 201 ROCKINGHAM MEMORIAL 174 Spotsylvania Regional Medical Center 169 SOUTHSIDE COMMUNITY 147 MEMORIAL HOSPITAL OF MARTINSVILLE 137 LEWIS GALE MONTGOMERY REGIONAL 123 CULPEPER REGIONAL HOSPITAL 116 WARREN MEMORIAL HOSPITAL 109 TWIN COUNTY REGIONAL 100 CARILION NEW RIVER VALLEY MEDICAL CENTER 94 JOHNSTON MEMORIAL 89 SMYTH COUNTY COMMUNITY HOSPITAL 86 WYTHE COUNTY COMMUNITY HOSPITAL 82 NORTON COMMUNITY 77 CARILION FRANKLIN MEMORIAL 77 WELLMONT LONESOME PINE HOSPITAL 74 HALIFAX REGIONAL 74 CARILION TAZEWELL COMMUNITY 65 LEWIS GALE PULASKI 65 MARTHA JEFFERSON 64 CARILION BEDFORD MEMORIAL 62 CLINCH VALLEY 61 BUCHANAN GENERAL HOSPITAL 56 RUSSELL COUNTY MEDICAL CENTER 54 * SHENANDOAH MEMORIAL 54 CENTRA GRETNA MEDICAL CENTER 50 * CARILION STONEWALL JACKSON 46 MOUNTAIN VIEW REGIONAL MEDICAL CENTER 36 LEWIS GALE ALLEGHENY 35 OUT OF AREA HOSPITAL 34 * CARILION GILES COMMUNITY 33 * PAGE MEMORIAL 32 * DICKENSON COUNTY HOSPITAL 30 Martha Jefferson ER at Forest Lakes 25 MWH LEE'S HILL 21 VA MEDICAL CENTER 20 **PIONEER COMMUNITY HOSPITAL 17 * BATH COUNTY COMMUNITY 5 VIRGINIA BAPTIST 1 TOTAL 5,061 * Denotes a critical access hospital ** Closed in the fall of 2017

5 5 Opioid Call Trends For added perspective, our data views opioid activity from the last 5 years. Figure 7: Trends in Naloxone Therapy Reported to the BRPC The number of opioid calls received by the BRPC decreased by 28%; from 1,143 in 2013 to 825 in the year 2017 (Fig. 5). Among the calls received by the BRPC for opioids in 2017, oxycodone (148 calls), hydrocodone (122 calls) and tramadol (100 calls) were the most commonly reported opioids (Fig. 6). Figure 5: Trends in Opioid Calls Figure 6: Most Frequent Opioids Reported Medical Outcome: All Confirmed Exposures The majority of human exposures reported to the BRPC resulted in no effect or minor effect. This included calls where either the outcome was reported directly from the caller or minimal toxicity was expected. Moderate or major effects were seen in 16.6% of the exposure cases. Other medical outcomes included 29 deaths, 643 potentially toxic exposures where follow-up was not possible, and 384 unrelated effects from reported exposures (Fig. 8). Figure 8: Medical Outcome of Confirmed Exposures From 2013 to 2017, there were 1,549 calls where naloxone therapy was reported to be performed or recommended (Fig. 7). In a majority of these calls (96%) naloxone was used prior to recommendation by the BRPC. The number of naloxone reporting calls increased by 22% from 2013 (268 calls) to 2017 (327 calls).

6 6 When medical outcomes of exposures are grouped by age, the data show that the severity of outcome increases with age (Fig. 9). Children younger than age 6, though responsible for the majority of calls to the BRPC, predominately experience no effects or minor effects as a result of their exposure. Figure 9: Medical Outcome of Exposures By Age Group the BRPC as well as unique studies arising directly from our center. These studies are performed with our trainees (undergraduate, graduate, and post-graduate) to further their education in research and are performed in association with numerous programs throughout the university. The medical toxicology staff publish a free monthly newsletter: ToxTalks. It is distributed electronically to a mailing list of nearly 400 health care professionals. Public Education and Outreach The BRPC supports an active poisoning prevention and outreach program for the general public with one full time Health Educator. In 2017, programs reached over 5,150 people. The poison center was represented at 12 regional health fairs. Fifty-one presentations were given to audiences, either in person or by webinar, on a variety of topics, including: Professional Education and Outreach The BRPC trains numerous professionals each year, including approximately 150 medical personnel-intraining who elect to be on our service for 2-4 week periods. These trainees include students (medical, nursing and pharmacy) and residents (medical and pharmacy). In addition, two physicians are currently being trained in our two-year Medical Toxicology Fellowship that is approved by the University of Virginia School of Medicine. Hundreds of professional education programs are conducted throughout Virginia each year by faculty associated with the BRPC, not only at the state level, but also nationally and internationally. Examples of professional presentations given by our staff include (but are not limited to): General Approach to the Poisoned Patient Management of the Critically Ill Poisoned Patient Appropriate Care of the Envenomated Patient New Trends in Drugs and Substances of Abuse Managing the Pediatric Overdose Epidemiology of Drug Dependence Currently, numerous multicenter collaborative studies are being performed at our center in association with Teen Trends in Substance Abuse Medicine Safety for Seniors Childhood Poisoning Prevention for Early Learning Professionals There were 56 media contacts including television and radio interviews, newspaper and magazine articles, and online news source articles. The BRPC has an active Twitter account with over 400 followers, and a Facebook page. In 2017 over 255,665 pieces of education material were distributed, including phone stickers, refrigerator magnets, posters, and wallet cards. During National Poisoning Prevention Week in March, the BRPC partnered with pharmacies by providing materials to be included in every prescription filled during that week. Seventy-nine pharmacies participated, and materials were distributed to approximately 39,750 households throughout the BRPC service area. In 2017 four issues of the free public education newsletter, The Antidote, were released. This newsletter reached thousands of Virginians by way of an electronic mailing list, viral sharing of electronic media, social media, distribution of hard copies, and visits to the website. Main articles featured safety information about eye exposures, art and craft products, essential oils, alcohol, and snakebites.

7 Published Abstracts Ngo DA, Holstege CP, Rege S. Ding C, Miley L, Rege S. Validity of code-based recording of alcohol intoxication among college students presenting to a university hospital emergency department. Ann Emerg Med 2017;70(4):S Presented at the American College of Emergency Physicians Research Forum. Washington, DC. October, 2017 Rege S, Ait-daoud N, Holstege CP. Trends in the reports of naloxone as reported to a regional U.S. poison center. Ann Emerg Med 2017;70(4):S138. Presented at the American College of Emergency Physicians Research Forum. Washington, DC. October, Rege S, Borek H, Rizer J, Ngo A, Holstege CP. Trends in the use of hydroxocobalamin or nitrites as antidotes: Ann Emerg Med 2017;70(4):S Presented at the American College of Emergency Physicians Research Forum. Washington, DC. October, Rege S, Holstege CP. Characteristics and predictors of tramadol misuse results from the 2015 National Survey on Drug Use and Health. Ann Emerg Med 2017;70(4):S Presented at the American College of Emergency Physicians Research Forum. Washington, DC. October, Rege S, Rizer J, Holstege CP. Epidemiology of gastrointestinal therapies reported to the poison centers: Ann Emerg Med 2017;70(4):S138. Presented at the American College of Emergency Physicians Research Forum. Washington, DC. October, Rege S, Ngo A, Borek H, Rizer J, Holstege CP, Patterns and correlates of antidote use reported to the poison centers. Clin Tox 2017;55(7):746. Presented at the North American Congress of Clinical Toxicology. Vancouver, Canada. October, Rege S, Ngo DA, Ait-daoud N, Holstege CP. National trends in the use of naloxone, Clin Tox 2017;55(7):833. Presented at the North American Congress of Clinical Toxicology. Vancouver, Canada. October, Rizer J, Rege S,Charlton N. Essential oil exposers in pediatric population: a 6-year review. Clin Tox 2017;55(7):795. Presented at the North American Congress of Clinical Toxicology. Vancouver, Canada. October, Rege S, Holstege CP, Ait-daoud N. Characteristics and predictors of oxycodone misuse: results from the 2015 National Survey on Drug Use and Health. Clin Tox 2017;55(7):794. Presented at the North American Congress of Clinical Toxicology. Vancouver, Canada. October, Rege S, Charlton N, Holstege CP, Rizer J, Kopatic M, Ait-daoud N. National trends and characteristics of buprenorphine exposures reported to U.S. poison centers, Clin Tox 2017;55(7):833. Presented at the North American Congress of Clinical Toxicology. Vancouver, Canada. October, Ngo DA, Holstege CP, Ait-daoud N, Ding C, Miley L. Trends in alcohol intoxication among students presenting to a university hospital emergency department using code-based records. Presented at the North American Congress of Clinical Toxicology. Clin Tox 2017;55(7):791. Vancouver, Canada. October, Ngo DA, Ait-Daoud N, Rege S. Ding C, Miley L, Holstege CP. Validity of code-based recording of alcohol intoxication among college students presenting to a university hospital emergency department. Presented at the American College of Emergency Physicians Research Forum. Washington, DC. October, 2017 Brill K, Rizer J, King J, Charlton NP. Acute hypersensitivity reaction to Crotalidae polyvalent immune Fab (CroFab) initially presenting as galactose-alpha-1,3-galactose (alpha-gal) allergy. Clin Tox 2017;55(5):379. Presented at the 37th International Congress of the European Association of Poison Centres and Clinical Toxicologists (EAPCCT). May, 2017, Basel, Switzerland. Thompson MA, Charlton NP, Rushton WF. Third degree heart block with accelerated junctional rhythm in verapamil overdose: a case series. Clin Tox 2017;55(5):465. Presented at the 37th International Congress of the European Association of Poison Centres and Clinical Toxicologists (EAPCCT). May, 2017, Basel, Switzerland. Rushton WF, Kurz N, Arnold J, Charlton, NP. Thromboelastography in suspected Crotalus horridus horridus envenomation. Clin Tox 2017;55(5):488. Presented at the 37th International Congress of the European Association of Poison Centres and Clinical Toxicologists (EAPCCT). May, 2017, Basel, Switzerland Publication Journal Articles Ait-Daoud N*, Blevins D, Khanna S, Sharma S, Holstege CP. Women and Addiction. Psychiatric Clinics of NA 2017;40 (2): Vakkalanka JP, Charlton NP, Holstege CP*. Epidemiologic Trends in Loperamide Abuse and Misuse. Ann Emerg Med. 2017;69(1): Murphy LT, Charlton NP. Prevalence and characteristics of inhalational and dermal palytoxin exposures reported to the National Poison Data System in the U.S. Environ Toxicol Pharmacol Oct;55: Gerardo CJ, Quackenbush E, Lewis B, Rose SR, Greene S, Toschlog EA, Charlton NP, Mullins ME, Schwartz R, Denning D, Sharma K, Kleinschmidt K, Bush SP, Ryan S, Gasior M, Anderson VE, Lavonas EJ. The Efficacy of Crotalidae Polyvalent Immune Fab (Ovine) Antivenom Versus Placebo Plus Optional Rescue Therapy on Recovery From Copperhead Snake Envenomation: A Randomized, Double-Blind, Placebo-Controlled, Clinical Trial. Ann Emerg Med Aug;70(2): Rizer J, Brill K, Charlton N, King J. Acute hypersensitivity reaction to Crotalidae polyvalent immune Fab (CroFab) as initial presentation of galactose-α-1,3-galactose (α-gal) allergy. Clin Toxicol (Phila) Aug;55(7): Borek HA, Rizer J, Ngo A. Fab Antivenom Controversy Continues. Ann Emerg Med Dec;70(6):