The clinical management of acetaminophen poisoning in a community hospital system: factors associated with hospital length of stay

N-Acetylcysteine for Preventing Acetaminophen-Induced Liver Injury: A Comprehensive Review

Aims: N-Acetylcysteine (NAC) is used as an antidote in acetaminophen (APAP) overdose to prevent and mitigate drug-induced liver injury (DILI). Our objective was to systematically review evidence of the use of NAC as a therapeutic option for APAP overdose and APAP-related DILI in order to define the optimal treatment schedule and timing to start treatment.

Methods: Bibliographic databases (PubMed, Web of Science, Embase, and MEDLINE) were searched for retrospective and prospective cohort studies, case series, and clinical trials. The prespecified primary outcomes were DILI-related mortality, hepatotoxicity, and adverse events (AEs).

Results: In total, 34 studies of NAC usage in APAP-related DILI cases with 19,580 patients were identified, of which 2,376 patients developed hepatotoxicities. The mortality rate across different studies ranged from 0 to 52%. Large variability of NAC regimens was found, i.e., intravenous (I.V.) (100–150 mg/kg) and oral (70–140 mg/kg), and length of treatment varied—12, 24, or 48 h for I.V. regimen and 72 h for oral administration. The timing of initiation of NAC treatment showed different results in terms of occurrence of hepatotoxicity and mortality; if started within 8 h and no more than 24 h from APAP overdose, either intravenously or orally, NAC administration was efficacious in terms of mortality. The most frequent AEs reported were anaphylactic reactions, followed by cutaneous AEs for the IV route and intestinal AEs for the oral one.

Conclusion: NAC improves hepatotoxicity and reduces mortality. Timing of treatment, ranging from 8 to 24 h from APAP overdose, regardless of the regimen or route of administration, is important to prevent or minimize liver damage, particularly in children and in elderly and obese patients.

Characterization of Regional Poison Center Utilization Through Geospatial Mapping

Introduction

Penetrance is the annual rate of human exposure calls per 1000 persons, a measure that historically describes poison center (PC) utilization. Penetrance varies by sociodemographic characteristics and by geography. Our goal in this study was to characterize the geospatial distribution of PC calls and describe the contribution of geospatial mapping to the understanding of PC utilization.

Methods

This was a single-center, retrospective study of closed, human, non-healthcare facility exposure calls to a regional PC over a five-year period. Exposure substance, gender, age, and zone improvement plan (ZIP) Code were geocoded to 2010 US Census data (household income, educational attainment, age, primary language) and spatially apportioned to US census tracts, and then analyzed with linear regression. Penetrance was geospatially mapped and qualitatively analyzed.

Results

From a total of 304,458 exposure calls during the study period, we identified 168,630 non-healthcare exposure calls. Of those records, 159,794 included ZIP Codes. After exclusions, we analyzed 156,805 records. Penetrance ranged from 0.081 – 38.47 calls/1000 population/year (median 5.74 calls/1000 persons/year). Regression revealed positive associations between >eighth-grade educational attainment (β = 5.05, p = 0.008), non-Hispanic Black (β = 1.18, p = 0.032) and American Indian (β = 3.10, p = 0.000) populations, suggesting that regions with higher proportions of these groups would display greater PC penetrance. Variability explained by regression modelling was low (R2 = 0.054), as anticipated. Geospatial mapping identified previously undocumented penetrance variability that was not evident in regression modeling.

Conclusion

PC calls vary substantially across sociodemographic strata. Higher proportions of non-Hispanic Black or American Indian residents and >eighth-grade educational attainment were associated with higher PC call penetrance. Geospatial mapping identified novel variations in penetrance that were not identified by regression modelling. Coupled with sociodemographic correlates, geospatial mapping may reveal disparities in PC access, identifying communities at which PC resources may be appropriately directed. Although the use of penetrance to describe PC utilization has fallen away, it may yet provide an important measure of disparity in healthcare access when coupled with geospatial mapping.

Economic evaluation of the direct cost resulting from childhood poisoning in Morocco: micro-costing analysis

Background

The analysis of the economic burden for childhood poisoning has great value in Morocco where there still exists a paucity of information on the subject. The objective of this study was to explore the economic costs of unintentional and intentional poisoning in children in the region of Rabat-Salé-Kénitra, Morocco.

Methods

A prospective study of children younger than 15 years with a poisoning diagnosis conducted between March and July 2016 in the Children’s University Hospital of Rabat, Morocco. The source of data for this study was questionnaire that collected information on the costs, the epidemiological and the socio-economic characteristics of childhood poisoning.

Results

Eighty-seven patients were interviewed during the study period (39 females and 48 males). The majority of poisoning cases (98.85%) were accidental and 1.15% were intentional. Drugs, snake bites and scorpion stings, carbon monoxide, food, plants, household products, illegal drugs, pesticides, petroleum and industrial chemicals products were caused the poisoning. Of all the hospitalized patients, 77 (88.5%) were admitted to the emergency department and 5 (5.7%) were admitted to the intensive care unit. The average direct medical costs and the average direct non-medical costs of providing poison treatment were USD 127 and USD 30 per child, respectively. Total average direct cost of USD 157 (127 + 30) represented 60% of the national minimum wage per month in Morocco. Total direct medical costs accounted for 80%, as against 20% direct non-medical costs. The mean ± SD length of stay (LOS) for children with poisoning was 2.15 ± 1.87 days with a range variated between 0 day and 10 days.

Conclusions

Overall, this study confirms that the costs of childhood poisoning are not negligible costs in Morocco. Therefore, the prevalence and the costs of childhood poisoning can be reduced by monitoring an open communication between parents, the Poison Control Centre of Morocco (MPCC) and physicians in order to increase the vigilance of parents against the risks related to unintentional poisoning that can be prevented with more awareness.

Cost Savings and Efficacy in Management of Paracetamol Poisoning in a 23-hours Emergency Department Observation Unit: A Comparison to Inpatient Care

Introduction

Emergency department observation units (EDOU) have been shown to be effective in decreasing hospitalization rates and length of stay (LOS) for various conditions. However, cost savings and efficacy in the management of poisoning in EDOU have not been widely studied. The objective of our study is to compare the costs and effectiveness of managing paracetamol poisoned patients in the EDOU with those treated in the inpatient wards.

Methods

We conducted a historical controlled observational study comparing paracetamol-poisoned patients (who received at least 21 hours of IV N-acetylcysteine [NAC]) admitted to the EDOU during 2013-2014 with similar patients admitted to inpatient ward during 2011, 2013-2014. 

Results

We found 136 patients admitted to the inpatient ward and 95 to our EDOU due to paracetamol poisoning but only 78 and 39 patients respectively fulfilled the inclusion criteria. Between the EDOU and inpatient ward groups, we found similar demographics, poisoning presentation, treatment, and adverse event profiles. There were no fatalities and only two patients (one from each group) developed hepatotoxicity. The "medical" length of stay was 31.9 hours shorter in the EDOU group compared to the inpatient ward group (23.3 versus 55.2 hours). EDOU patients have statistically significant savings (comparing bill size) of S$784 per patient.

Conclusions

Admission to the EDOU resulted in significant cost savings and 58% decreased LOS when compared to inpatient wards. The EDOU is a cost-effective and safe alternative for the management of selected paracetamol poisonings requiring NAC. Further studies would be needed to verify these results. 

The Effect of a Medical Toxicology Inpatient Service in an Academic Tertiary Care Referral Center

INTRODUCTION

Morbidity and mortality from poison- and drug-related illness continue to rise in the USA. Medical toxicologists are specifically trained to diagnose and manage these patients. Inpatient medical toxicology services exist but their value-based economic benefits are not well established.

METHODS

This was a retrospective study where length of stay (LOS) and payments received between a hospital with an inpatient medical toxicology service (TOX) and a similar hospital in close geographic proximity that does not have an inpatient toxicology service (NONTOX) were compared. Controlling for zip code, demographics and distance patients lived from each hospital, we used a fitted multivariate linear regression model to identify factors associated with changes in LOS and payment.

RESULTS

Patients admitted to the TOX center had 0.87 days shorter LOS per encounter and the hospital received an average of $1800 more per patient encounter.

CONCLUSION

In this study, the presence of an inpatient medical toxicology service was associated with decreased patient LOS and increased reimbursement for admitted patients. Differences may be attributable to improved direct patient care provided by medical toxicologists, but future prospective studies are needed.

Rational use of paracetamol among out-patients in a Bhutanese district hospital bordering India: a cross-sectional study

OBJECTIVE

Paracetamol or acetaminophen is a weak analgesic commonly used worldwide and in Bhutan. It is available across all levels of Bhutan's health care system and for purchase without prescription. Little is known, however, about patterns of paracetamol use in Bhutan. This study aimed to assess what the Bhutanese population knows about the indications for use of paracetamol, safe use, and common patterns of usage (frequency, dosage). These questions were studied among Bhutanese living in Phuentsholing, a large commercial town at Bhutan-India border.

RESULTS

Among 441 participants, most (72.1%) reported having used paracetamol in the past 1 year. The mean knowledge score was 57.6%; only 30 participants (6.8%) had what was characterized as "good knowledge." Level of knowledge was positively associated with level of education (p = 0.031). Less than half (41.3%) had a "good attitude" towards use of paracetamol. In practice, few (4.8%) knew the correct dose, including about one in ten who reported exceeding the recommended therapeutic dose. Most knew about side effects (61.2%) and possible allergic reactions (77.3%). Many participants (47.9%) acknowledged that the self-use of paracetamol may not reduce the number of hospital visits.

Effect of a medical toxicology admitting service on length of stay, cost, and mortality among inpatients discharged with poisoning-related diagnoses

There are no published studies that have compared quality outcomes of hospitalized poisoned patients primarily under the care of physician medical toxicologists to patients treated by non-toxicologists. We hypothesized that inpatients primarily cared for by medical toxicologists would exhibit shorter lengths of stay (LOS), lower costs, and decreased mortality. Patients discharged in 2010 and 2011 from seven hospitals within the same health care system and greater metropolitan area with Medicare severity diagnosis-related groups for "poisoning and toxic effects of drugs" with and without major comorbidities or complications (917 & 918, respectively) were identified from a Premier® database. The database contained severity-weighted comparisons between expected and observed outcomes for each patient. Outcome parameters were differences between expected and observed LOS, cost, and percent mortality. These were then compared among groups of patients primarily admitted and cared for by (1) medical toxicologists at one hospital (Banner Good Samaritan Medical Center, BGS), (2) non-toxicologists at BGS, and (3) non-toxicologists at six other hospitals. Records of 3,581 patients contained complete data for assessment of at least one outcome measure. Patients cared for by medical toxicologists experienced favorable differences in LOS, costs, and mortality compared with other patient groups (p < 0.001). If patients cared for by non-toxicologists had experienced similar differences in observed over expected values for LOS, cost, and mortality as those cared for by medical toxicologists, there would have been a median savings of 1,483 hospital days, $4.269 million, and a significant decrease in mortality during the 2-year study period. Differences between observed and expected LOS, cost, and mortality in patients primarily cared for by medical toxicologists were significantly better than in patients cared for by non-toxicologists, regardless of facility. These data suggest that significant reductions in patient hospital days, costs, and mortality are possible when medical toxicologists directly care for hospitalized patients.

Billing and reimbursement for a bedside toxicology service at a tertiary care academic center during its first fiscal year

A bedside toxicology consult service may improve clinical care, facilitate patient clearance and disposition, and result in potential cost savings for poisoning exposures. Despite this, there is scant data regarding economic feasibility for such a service. Previously published information suggests low hourly reimbursement at approximately $26.00/h at the bedside for toxicology consultations. A bedside toxicology consultant service was initiated in 2011. Coverage was available 24 h a day for 50 out of 52 weeks. Bedside rounding on toxicology consult patients was available 6/7 days per week. The practice is associated with >800 bed teaching institution in a large upstate NY region with elements of urban and suburban practice. Demographic and billing data was collected for all patients consulted upon from July 1, 2011 to June 31, 2012. In charges of $514,941 were generated during the period of data collection. Monthly average was $42,912. Net reimbursement of charges was 29 % of overall charges at $147,792. In terms of total encounters, net collection rate in which something was reimbursed or "paid" against charges for that encounter was 82.6 % of all encounters at 999/1,210. Average encounter time for inpatients, including critical care, was 1.05 h, and the average time spent for outpatients was 1.18 h. Reimbursement rates appear higher than previously reported. Revenue generated from reimbursement from toxicology consultation can result in recouping a substantial portion of a toxicologist's salary or potentially fund fellowship positions and salaries or toxicology division infrastructure.

A survey of poison center knowledge and utilization among urban and rural residents of Arizona

Background

Poison control centers (PCCs) hold great potential for saving health care resources particularly by preventing unnecessary medical evaluations. We developed a survey to better identify the needs and experiences of our service community. We hope to use these data to improve PCC outreach education and overall use of our services.

Method

A written questionnaire was developed in English and then translated into Spanish. Subjects agreeing to participate were then asked two verbal questions in English: are you at least 18 years of age? And; in what language would you like to complete the questionnaire; English or Spanish? All questionnaires completed by subjects ≥18 years of age were included. Questionnaires with missing responses, other than zip code, were included. Data collected include gender, age, zip code, primary language, ethnicity, education, health insurance status and experiences with the PCC. Subjects were not compensated for participation. Arizona zip codes were divided into “rural” or “urban” based on a census data website. Percentages and odds ratios were determined based on completed responses. Smaller subgroups, for some variables, were combined to increase sample sizes and improve statistical relevance.

Results

Overall, women and subjects with children at home (regardless of ethnicity) were significantly more likely to have heard of the PCC although Blacks and Spanish-speakers were significantly less likely to have heard of the PCC. Similarly, respondents with children at home and those reporting a prior home poisoning (regardless of ethnicity) were significantly more likely to have called the PCC. Blacks were significantly less likely to have called the PCC. These findings were similar among people living in urban zip codes but not statistically significant among rural responders.

Conclusions

Based on a small survey, race and language spoken at home were variables identified as being associated with decreased awareness of poison centers. Focusing on these specific groups may assist in efforts to increase PCC penetrance, particularly among urban communities.

A Survey of Primary Care Offices: Triage of Poisoning Calls without a Poison Control Center

Poison control centers hold great potential for saving health care resources particularly by preventing unnecessary medical utilization. We developed a four-question survey with three poisoning-related scenarios, based on common calls to our poison center, and one question regarding after-hours calls. We identified primary care provider offices in our poison center's region from an internet search. We contacted these offices via telephone and asked to speak to an office manager or someone responsible for triaging patient phone queries. Using a scripted form, trained investigators questioned 100 consecutive primary care provider offices on how they would handle these poisoning-related calls if there was no poison center to refer their patients to. Results of our survey suggest that 82.5% of poisoning-related calls to primary care offices would be referred to 911 or an emergency department if there was no poison center. These results further support the role that poison centers play in patient care and health care utilization.