Sir Charles Gairdner Hospital

The Queen Elizabeth II Medical Centre

Hospital Avenue, Nedlands, Perth, WA

Australia, 6009

Phone: Administration 08 9346 1943

Phone 24 hours - 13 11 26

Western Australian Poisons Information Centre Annual Report

2011

Table of Contents

1. Introduction ................................................................ 3

2. Preventative activities .......................................................... 3

3. Training activities for professionals ................................................. 3

4. Current research activities and recent publications ....................................... 3

5. Data provision to agencies ....................................................... 4

6. Local, national and international meetings, and cooperative activities of the centre ................. 4

7. Personnel .................................................................. 5

8. Call recording ............................................................... 6

9. Phone call numbers and characteristics .............................................. 6

10. Case statistics .............................................................. 10

1. Introduction

The Western Australian Poisons Information Centre (WAPIC) provides telephone consultation to the general public and medical professionals in cases of poisoning or suspected poisonings. The Centre also provides advice on poisoning prevention, drug information, first-aid management of exposures, and the identification of toxic agents. The WAPIC is located at Sir Charles Gairdner Hospital in Perth and is closely associated with the hospital’s Emergency Department and the Western Australian Clinical Toxicology Group. Complex cases are referred to the on-call Clinical Toxicologist.

The WAPIC serves Western Australia, South Australia, and the Northern Territory; a total population of 4.2 million, according to the Australian Bureau of Statistics. Operational hours: 08:00 to 22:00 h, seven days per week (WST) and extended from 08:00 to 04:00 h two days per week. Outside these hours calls are diverted to the NSW, Queensland or Victorian Poisons Information Centres (PIC’s).

Access to the service is via the 13 11 26 phone number, which is charged at the cost of a local call from any landline in Australia.

2. Preventative activities

Our centre collaborates with Kidsafe WA and the Injury Control Council of Western Australia. Printed material was supplied to community groups, including child health centres, day care centres and to interested members of the general public. Information is provided on first-aid management of poisonings and envenoming, and the safe storage and use of household chemicals.

3. Training activities for professionals

On-going training and education was provided through attendance of fortnightly case conferences held by the Clinical Toxicologists and weekly education sessions. In addition, a representative attends the bi-monthly national clinical meetings held at the NSWPIC. At these meetings case presentations are made and consensual case management guidelines are formulated.

Clinical placement was provided for two, final year Curtin University, Bachelor of Pharmacy students and lectures were given to Curtin University, Post-graduate Diploma of Pharmacy students.

4. Current research activities and recent publications Gibson NP, Jelinek GA, Jiwa M, and Lynch A-M. “Paediatric frequent attenders at emergency departments: a linked-data population study”. J.Paediatr.Child Health, 2010 Dec; 46(12):723-728. Little M, Murray L, and Lynch A-M. “Improving our knowledge about jellyfish stings and initial first-aid management”. (Recruitment in progress).

5. Data provision to agencies

Cases of Lye water exposure, for the period of January to September 2011, provided to the SA Department of Health. Cases of poisonings due to formulated caffeinated beverages (energy drinks) provided to the NSW Department of Health. Retrospective analysis of cases of paediatric ingestion of the lignocaine containing Women and Children’s Hospital Mouth Paint®; for the period, January 2008 to August 2011, data provided to the SA Department of Health. As part of The Denver Prescription Drugs of Abuse Study, WAPIC cases (October 2010 to October 2011) involving methylphenidate, dexamphetamine, methadone, oxycodone and buprenorphine provided to the NSWPIC . WAPIC data on paediatric exposures (ingestion and ocular) to alcohol-based hand lotions (2009-2011) supplied to the The Royal Women’s Hospital, Melbourne. South Australian cases of exposure to hazardous wastes, including pesticides (January 2010 to December 2010) supplied to Zero Waste South Australia. WAPIC cases handling 2011, data supplied to the Department of Health, Pharmaceutical Services Branch.

WA cases of exposure to synthetic cannabis (spice, kronic) from January 2008 to April 2011, provided to WA Department of Health. Case details of all accidental paediatric ingestions involving pharmaceuticals and chemicals where the caller was a grandparent (January 2010 to May 2011) supplied to the Department of Paediatrics, Royal North Shore Hospital, Sydney, NSW. 6. Local, national and international meetings, and cooperative activities of the centre August 3, 2011. Representatives from the three clinical toxicology units: Sir Charles Gairdner Hospital, Royal Perth Hospital and Fremantle Hospital and the WAPIC met with the Public Health division of the WA Department of Health at Grace Vaughan House in Shenton Park, with the view of establishing links between the Clinical Toxicology units, the WAPIC and a number of departments within the Environmental Health and the Environmental Hazards Units. Christine Duncan and Nick Merwood attended the national poisons information centre meeting in Melbourne.

7. Personnel

Medical Director

Dr Jason Armstrong, MBChB, FACEM

Administrative Director (Head of Department)

Dr Ann-Maree Lynch, BSc.(Hons), PhD

Specialists-Poisons Information

Mr Kasra Ahmadi, BSc., BPharm.

Mr Klaus Auert, BPharm., MPS

Mrs Dale Beecham, BPharm., MPS

Mr Tony Coltrona, BPharm., MPS

Ms Christine Duncan RN B.Sc. (Nursing) Grad.Cert. (Crit Care, Infection Control), PGDip (Crit Care).

Mr Mechaiel Farag, BPharm., MPS, MSHP

Ms Esterita Frano, BSc.(Hons), BPharm., MPS

Miss Teresa DiFranco, BSc.

Mr Donald Hulme, BSc., BPod., MPharm.

Mrs Bridgett McKay, BPharm., MPS

Mr Nick Merwood, BSc., MPharm, MPS

Mrs Shirley Murphy, BPharm.,

Ms Yumi Tan, BPharm., Grad.Dip.Pharm, MPS

Mr Ray Thomas, BPham., MPS

Medical Consultants

Dr Jason Armstrong, MBChB, FACEM

Dr Ovidiu Pascu, MD, FACEM

Dr David McCoubrie, MBBS, FACEM

Dr Jessamine Soderstrom, MBBS, FACEM, Grad. Cert.Tox.

Toxicology Fellows

Dr Kerry Hoggett, MBBS, Grad.Cert.Clin.Tox., FACEM

Dr Alan Gault, MBChB, BAO, BA, HSc., FACEM

8. Call recording

Call details are entered directly into a computer database, the INTOX Data Management System, which was developed by the International Programme on Chemical Safety and the World Health Organisation, Geneva, Switzerland and is maintained by the Canadian Centre for Occupational Health and Safety, Ontario, Canada.

9. Phone call numbers and characteristics

(a) Number of incoming phone calls by state of origin (Table 1)

(b) Monthly call volume (Graph 1)

(c) Incoming phone calls by category of caller (Table 2)

(d) Number of cases, incidents and request for information (Table 3)

(e) Comments

a) Table 1: Number of incoming phone calls by state of origin

Incoming phone calls Total calls %

Western Australia 20676 52.7

South Australia 14160 36.1

Northern Territory 1599 4.1

New South Wales 1236 3.1

Victoria 666 1.7

Queensland 733 < 1

Australian Capital Territory 54 < 1

Tasmania 60 < 1

Overseas 13 < 1

Unknown/not recorded 54 < 1

TOTAL 39251 100

(b) Graph 1: Monthly call volume

(c) Table 2: Incoming calls by category of caller

Caller Total calls

Family member/victim

Parent 14637

Grandparent 547

Partner 1347

Family- not-specified 2761

Victim 7140

Health personnel

Physician 4559

Non-physician, medical 2996

Ambulance officer 351

Veterinary personnel 617

Health - other 98

Other personnel

Carer 2207

Social worker /counsellor 62

Education worker 163

Police and other emergency services

76

Other personnel-not specified 114

Other 1490

Unknown/not recorded 86

TOTAL 39251

(d) Table 3: Number of cases, incidents and requests for information

Call type Number

Cases 29933

Incidents 20

Requests 7451

TOTAL 37404

(e) Comments

A total of 39251 phone calls were handled by the WAPIC in 2011, of which 29933 were cases of exposure.

Incoming phone calls are classified as cases, incidents or requests (CIR’s). One or more phone calls can be recorded for each CIR. A case is defined as a record of exposure or potential exposure of an individual to an agent. Requests include drug information calls, such as drug information in pregnancy and lactation, advice on chemical safety, details on product constituents and requests for printed information. An incident is defined as an event leading to exposure or potential exposure involving one or many victims in which victim details were not available at the time of the first phone call.

10. Case Statistics

(a) Victims of poisoning (Table 4)

(b) Initial severity – human cases (Table 5)

(c) Human case number by gender (Table 6)

(d) Case number by age group (Table 7)

(e) Route of exposure – human cases (Table 8)

(f) Location of exposure – human cases (Table 9)

(g) Case number by circumstance of exposure and age group (Table 10)

(h) Number of human cases by location of treatment pre-inquiry (Table 11)

(i) Recommended treatment location for human cases where treatment pre-inquiry was the location of the poisoning (Table 12)

(j) Top 10 agents - human cases (Table 13)

(k) Comments

(a) Table 4: Victims of poisoning

Species Number

Human 28123

Dog 1599

Cat 158

Bird 12

Other 41

TOTAL 29933

(b) Table 5: Initial severity –human cases

Severity* Number

None 15528

Minor 10756

Moderate 1162

Severe 147

Fatal 2

Unknown/ not recorded

528

TOTAL 28123

*Severity at the time of the initial call to the WAPIC and is scored as per the Poison Severity Score – Persson, H.E., Sjoberg, G.K., Haines, J.A. and Pronczuk de Garbino, J. (1998) Clinical Toxicology, 36(3): 205-213.

(c) Table 6: Human case number by gender

Gender Number

Male 13278

Female 14405

Unknown/not recorded

440

TOTAL 28123

(d) Table 7: Case number by age group

Age category Count Percentage

Neonate 28 < 1

Infant 1463 5.2

Toddler 11359 40.4

Child 2420 8.6

Adolescent 1247 4.4

Adult 10925 38.9

Elderly 654 2.3

Unknown/Unspecified 27 < 1

(e) Table 8: Route of Exposure – human cases

Route Number %

Ingestion 18815 60.1

Inhalation 1397 4.5

Cutaneous 2976 9.6

Ocular 1700 5.5

Otic 21 < 1

Bite 2277 7.3

Sting 789 2.5

Injection 231 <1

Mucosal:buccal 2581 8.3

Mucosal:nasal 56 < 1

Mucosal:rectal 10 < 1

Mucosal:unspecified 63 < 1

Other 13 < 1

Unknown/not recorded 69 < 1

TOTAL* 30372 100

* This is the total number of exposure routes, not case number. Multiple routes of exposure were recorded in many cases.

(f) Table 9: Location of exposure – human cases

Location of exposure Case number

Home and surroundings 25839

Work place

Workplace:Agricultural/horticultural workplace

142

Workplace:Factory 37

Workplace:Mine site

57

Workplace:Other

563

Medical-hospital

Medical - hospital:Inpatient facility 195

Medical – hospital:Nursing Home/Hospice 264

Medical - hospital:Other 13

Medical - non hospital 84

Enclosed public space

Enclosed public space:Shop 72

Enclosed public space: Leisure facility 22

Enclosed public space: Other 41

Prison 35

Mode of transport 64

Education Facility 201

Open space 238

Other 51

Unknown/not recorded 205

TOTAL 28123

(g) Table 10: Case number by circumstance of exposure and age group – See Appendix

(h) Table 11: Number of human cases by location of treatment pre-inquiry

Location of pre-inquiry treatment

Number of cases %

Location of poisoning 23194 82.5

During transport 89 < 1

Community Health Centre 474 1.7

Hospital 4305 15.3

Other 47 < 1

Unknown/not recorded 14 < 1

TOTAL 28123

(i) Table 12: Handling of human cases where the victim was at the location of the poisoning

Location of recommended treatment

Number of cases %

Location of poisoning 18390 79.3

Community Health Centre 959 4.1

Hospital 3819 16.5

Other 20 < 1

Unknown/not recorded 6 < 1

TOTAL 23194

(j) Table 13: Top 10 agents - human cases

Substance Count

Paracetamol 1927

Simple detergents and soaps 1469

Ethanol 1146

Benzodiazepines 885

Caustic Alkalis 881

Antibiotics 757

Selective serotonin reuptake

inhibitors

689

Ibuprofen 667

Chemical-unidentified 565

Spider-unidentified 498

31, 097 substances in 23,194 human cases

(k) Comments

Our centre handled 28123 cases of human exposures in 2011. At the time of the phone call, 45% the victims were either displaying clinical features or biochemical evidence of poisoning. Our centre does not routinely follow-up calls and so final severity is not known in the majority of cases.

Children were the victims in 54% of all cases, with toddlers (1 to 4 years) involved in 40% of all reported exposures. The most common childhood exposures were accidental, occurred in the home and involved pharmaceuticals or common household products. Adults were the victims in 39% of cases. Forty four percent of adult exposures resulted from unintentional accidents and 20% from deliberate attempts of self harm. The most common agents involved in suicide attempts were pharmaceuticals.

The most common route of exposure was ingestion (60% of cases). Bites and stings accounted for 9.8% of exposures, and mucosal exposures (predominately oral) were common in cases involving toddlers.

The most common agent involved in human cases was paracetamol. Ethanol due its ubiquity (household cleaning products, industrial products, perfumes and other cosmetics) was the third most common agent.

At the time of the phone call to the WAPIC, 82.5% of the victims were at the location of poisoning and 17% had either reached a health care facility or were in transit. It is noteworthy that 79% of the victims that were at the location of the exposure at the time the first phone call were able to be managed at that site due to the advice of the Poisons Centre; thus substantially limiting unnecessary hospital attendances and conferring considerable health care savings.

References

http://www.who.int/ipcs/publications/training_poisons/guidelines_poison_control/en/index.html

Appendix- Table 10: Case number by circumstance of exposure by age group Neonate/Infant < 12 months; Toddler = 1 to 4 years; Child = 5 to 14; Adolescent = 15 to 19; Adult = 20 to 75; Elderly > 75 years.

Circumstance Neonate/Infant Toddler Child Adolescent Adult Elderly Unknown Total %

Unintentional

Accidental 1149 10606 1704 351 4854 226 20 18910 67.2

Occupational 0 0 2 19 622 1 0 644 2.3

Therapeutic error 311 659 393 107 1836 341 2 3649 13.0

Environmental 0 3 2 0 20 1 0 26 < 1

Fire 0 0 2 0 3 2 0 7 < 1

Misuse 1 0 3 6 35 2 0 47 < 1

Food poisoning 3 5 6 1 52 5 0 72 < 1

Other 6 29 10 6 27 1 0 79 < 1

Unknown 4 4 9 7 35 4 2 65 < 1

Intentional

Suicide 0 0 134 568 2207 14 0 2923 10.4

Misuse 0 1 17 28 124 2 0 172 < 1

Abuse 0 0 37 74 243 3 1 358 1.3

Malicious /criminal 2 3 10 14 65 3 0 97 < 1

Other 2 3 10 7 62 3 0 87 < 1

Unknown 0 0 0 10 54 1 0 65 < 1

Adverse reaction

Food 3 4 4 2 20 2 0 35 < 1

Drug 9 31 45 25 502 31 0 643 2.3

Other 0 6 4 7 81 6 0 104 < 1

Unknown 1 0 2 2 23 2 0 30 < 1

Other 0 0 14 1 16 2 0 33 < 1

Unknown 0 5 12 12 44 2 2 77 < 1

TOTAL 1491 11359 2420 1247 10925 654 27 28123 100