The Role of a Regional Poison Center in Assessing and Managing Disaster Risk

Identifying and Addressing Health Risks

Since 1957, The Nebraska Regional Poison Center (NRPC) has provided poison control services to Nebraska, American Samoa, the Federated States of Micronesia, Idaho, and Wyoming. The NRPC is 1 of only 8 of the 55 poison centers in the United States ¹⁴ that serve a region larger than its home state. ¹⁷ The NRPC mission is to provide timely, evidence-based guidance to assist healthcare providers and the general public with the medical management of poisoned individuals, education for healthcare professionals and the public, and support for public health initiatives throughout its region. The center is staffed 24/7 by experienced registered nurses and pharmacists nationally certified by the American Association of Poison Control Centers as specialists in poison information and by physicians board certified in medical toxicology. These healthcare professionals have received specialized training on the assessment and management of CBRN hazards.

Managing Risks through Assessment and Recommendations

Routine hazmat incidents require expert, reliable assistance with the medical management of victims. ⁶ The primary role of NRPC staff during these incidents is to assist first responders, healthcare providers, and the public by assessing and managing the risk of individuals potentially or actually exposed to CBRN hazards. This rapid risk assessment is accomplished by obtaining a complete history, assessing the severity of each exposure through use of clinical guidelines and other specialized resources, and providing patient-specific treatment recommendations, including guidance on administration of antidotes as needed. Center staff assist first responders with risk management by assessing potential toxicity, identifying immediate dangers to responders and exposed individuals, and providing on-scene triage and clinical management advice. In addition, the NRPC team helps identify the hazardous material(s) involved, based on symptoms and victim exposure history, and notifies receiving hospitals about incoming patients. Videoconferencing is available for visual assessment of patients when indicated. Follow-up risk mitigation continues until patients are medically stable; and, for patients managed at home, until they are asymptomatic and/or no longer at risk for toxic effects from the exposure. Risk identification and management are foundational areas of expertise exhibited by NRPC specialists in poison information and medical toxicologists and are critical to disaster health response.

During CBRN/PH incidents, the NRPC's fundamental role of providing exposure risk assessment and treatment recommendations may be expanded to include facilitating widespread incident notification, staffing public health hotlines, and locating antidotes. Since early notification and accurate clinical management information is essential for healthcare providers to assess and manage exposure risks, the NRPC develops and sends incident-specific notifications and clinical management guidelines to providers and public health agencies in the affected and surrounding areas to help prepare them for a potential influx of casualties. Incident-specific hotlines are established in partnership with public health to assist healthcare professionals and the public. The NRPC team also fields requests for medical countermeasure (MCM) medications and coordinates the location and transfer of the medications.

Managing Risks through Medication Tracking

During CBRN/PH incidents, medications needed to treat victims may be in short supply or not routinely stocked by healthcare facilities. ¹⁸ Chemical antidotes are often needed urgently and the lack of immediate availability can pose a risk to adequate clinical management. ¹⁹ To mitigate this risk, the NRPC maintains an inventory of MCM medications needed for disaster health response, ²⁰ including the quantity of each medication available in each acute care hospital in the NRPC service area. The inventory includes medications that treat biological (eg, anthrax, plague), chemical (eg, nerve agents, cyanide), nuclear, radiological (eg, radiological dispersal devices, nuclear power plant leaks), and infectious disease (eg, influenza, rabies) exposures. This comprehensive inventory, available only to NRPC staff, is updated annually through a survey conducted with public health and healthcare facilities across the region. When the NRPC is contacted by healthcare providers or health departments and asked about the availability of MCM medications, the specialist in poison information provides the caller with the most recent list of hospitals with the medication on hand during the last survey and helps the callers contact hospital pharmacies to locate the medications.

In addition to maintaining regional situational awareness of hospital MCM medication availability, the NRPC has local- and state-level partnerships with key stakeholders who lead disaster health planning and response activities (Figure 1). These partnerships give NRPC personnel with toxicology expertise the opportunity to assist stakeholders with managing risks by providing clinical guidance on recognizing and managing CBRN and other potentially toxic exposures. The NRPC actively works with public health agencies to formulate treatment protocols and provides recommendations on stocking and use of antidotes and other disaster-related medications. These strong relationships help the NRPC maintain situational awareness of local and regional incidents across the state.

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Figure 1.

Nebraska Regional Poison Center Integration with Local and State Emergency Preparedness Stakeholders

Managing Risks through Coalitions and Integration

Since 1999, the Omaha Metropolitan Healthcare Coalition (OMHCC) has been one of the NRPC's critical partners in the assessment and management of disaster risk, and the two have been strongly integrated and aligned in several major capacities. First, the NRPC oversees the grant funds that support the OMHCC. This involves administration of the hospital preparedness program grant subaward, which includes fiscal and strategic oversight of the award and employing the healthcare coalition coordinator. In addition, the NRPC director serves on the OMHCC Executive Committee, which provides operational oversight of the healthcare coalition.

While the NRPC assists all of Nebraska's healthcare coalitions, the OMHCC serves the largest population in Nebraska and its pharmacy workgroup maintains a stockpile of emergency pharmaceuticals (eg, hydroxocobalamin, ciprofloxacin) to be shared statewide during disasters. The NRPC director has served as chairperson of the OMHCC Pharmacy Workgroup since its inception in 1999. This workgroup, with active participation from Omaha metropolitan area emergency medical services (EMS), county health departments, and pharmacists from most area hospitals and Offutt Air Force Base, has worked closely with the Omaha metropolitan area healthcare community to perform risk assessments, gap analyses, and develop action plans to address the area's pharmaceutical needs during CBRN/PH incidents. Decisions regarding purchase of types and amounts of these pharmaceuticals are based on periodic risk assessments performed by the Pharmacy Workgroup. These risk assessments are based upon the annual survey conducted by the NRPC of existing types and amounts of medications located within the community, priority threats (eg, proximity to nuclear power plant), the need for rapid medication availability (eg, chemical antidotes), and advice from public health and other subject matter experts. The medications are purchased by the OMHCC and distributed to EMS agencies and hospitals located within the coalition. A centralized antibiotic cache, which is distributed under the direction of local and state public health departments, can be initiated by contacting the NRPC. These caches are separate from the federal Strategic National Stockpile assets and are managed by the OMHCC Pharmacy Workgroup.

The overall goals of the Pharmacy Workgroup are to address pharmaceutical needs for the region and to support local and state public health agency plans to receive and distribute assets from the Strategic National Stockpile. The primary functions of the Pharmacy Workgroup include (1) assessing pharmaceutical needs and availability, (2) providing oversight of OMHCC medication caches (purchase, package, distribute, track, transfer, replace), and (3) providing 24/7 access to the OMHCC medication caches through the NRPC for healthcare providers who need to request them. Once the request is made, the NRPC works with other OMHCC partners to coordinate the release and transfer of medications. This is done by (4) assisting local, state, and regional public health personnel and healthcare providers to locate MCM medications needed on an emergent basis and (5) developing and updating evidence-based training materials and clinical treatment guidelines located on the NRPC website. ²¹ An example is the CBRN Agents Overview reference guide, which has been widely distributed statewide (Figure 2). ²² This guide is also used for just-in-time training of healthcare providers who contact the NRPC with information needs. The Pharmacy Workgroup also supports local and state public health department personnel by (6) providing compounding and dispensing advice and (7) assisting with distribution of Strategic National Stockpile pharmaceuticals when needed.

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Figure 2.

CBRN Agents Overview and Quick Reference Guide

Over the past several years, the NRPC has received several requests for OMHCC emergency medications and has assisted with the transfer of these medications that were used in the state of Nebraska. The cache was also used internationally after a request was made to the NRPC for Prussian blue capsules, which were sent with a medical team from Nebraska who traveled to Japan to assist in the aftermath of the 2011 earthquake and tsunami.

NRPC staff and Pharmacy Workgroup members formalized operational processes with the Douglas County Health Department, the county in which the greater Omaha metropolitan area is located, to reduce risk during public health emergencies by facilitating a rapid response when medications are needed. Health department personnel utilize the NRPC as their 24/7 point of contact when emergency pharmaceuticals are needed in their jurisdiction. NRPC specialists in poison information follow a process to contact OMHCC-area hospital pharmacy managers, since these individuals can quickly authorize the release and movement of medications from their facilities and are able to determine whether the medications are available from regional pharmaceutical suppliers. In addition to this process built into the Douglas County Health Department response plan, the NRPC also provides assistance to other health departments across Nebraska with disaster risk management by locating emergency pharmaceuticals and arranging for their delivery in a timely manner. To illustrate this critical service, the NRPC was contacted by 5 health departments for assistance with locating tetanus vaccines and other medications following the widespread flooding throughout Nebraska in March 2019. In partnership with the OMHCC Workgroup pharmacists, the NRPC filled those requests. A sixth health department also contacted the NRPC to request help to provide prescription medications and medical supplies to people evacuated to and living in shelters. NRPC and Pharmacy Workgroup team members arranged for community pharmacies to donate and deliver medications and medical supplies to these shelters. In addition, during the flooding, an OMHCC-area fire department contacted the NRPC for assistance managing calls from residents who were stranded in their homes for several days due to flooded roads and had run out of their prescription medications. The NRPC set up a hotline for residents to access so specialists in poison information could determine their needs for prescription refills and then coordinated those requests with a single community pharmacy that filled the prescriptions. Fire department personnel delivered the prescriptions to the neighborhood residents by boat. As a result of the many years of planning, exercising, and forming community partnerships, the NRPC was able to successfully contribute to the public health response during this statewide disaster.

Although it is not made publicly available, the Nebraska State Emergency Operations Plan explicitly calls out the paramount role played by the NRPC and its core functional support to the Nebraska Department of Health and Human Services (DHHS) with health and medical equipment and supplies. In partnership with Nebraska DHHS, the NRPC is the coordinating entity for CHEMPACK deployment and provision of subject matter expertise on the use of CHEMPACK pharmaceuticals for the treatment of nerve agent exposures. The NRPC maintains situational awareness of the specific locations of the state's 12 CHEMPACKs and, when contacted, can mobilize resources quickly.

Assessment and Management through Statewide Hotlines

Through its involvement in operating several statewide hotlines, the NRPC plays a critical role in the Nebraska DHHS response to CBRN/PH incidents in the state. Serving as a system of public health alert and warning of sorts, this partnership enables the NRPC to maintain familiarity with public health stakeholders across the state and with Nebraska DHHS response capabilities. Most importantly, operation of these hotlines provides the NRPC with the situational awareness to manage risks by mitigating gaps in response capabilities and efforts. These hotlines are used to report and respond to concerns related to CBRN/PH incidents, including infectious disease exposures to H1N1 influenza and the Ebola virus.

Nebraska DHHS is required to have in place a system to receive and respond to queries and reports of suspected and confirmed infectious disease, chemical, and radiation exposures. ²³ The system must be operational 24/7 and must be able to receive immediately notifiable condition and reportable disease reports and notify the appropriate on-call public health professional of immediately notifiable condition reports within 15 minutes. Queries and reports are received from public health and private healthcare providers, hospitals, medical laboratories, veterinarians, law enforcement, and other professional emergency responders. The general population can also access this phone number. The NRPC operates this professional public health reporting line for Nebraska DHHS using guidelines and a situation-specific call down list when responding to queries, reports, and public health emergencies.

Discussion

The value that poison centers bring to health security risk assessment and management is well documented.^1,11,15,25 It is estimated that poison centers save more than $1 billion in healthcare costs annually in the United States. ²⁵ According to Woolf et al, poison centers “direct more effective use of laboratory testing, antidotes, and patients' care, shortening length of hospital stay and leading to improved health care. [They also] develop and implement national guidance to reduce unnecessary variation in medical care and to ensure that the triage and treatment of the poisoned patients are evidence-based.” ¹ Attention has been drawn to the critical importance of reliable information resources that need to be accessed during chemical terrorist or hazardous events. ⁶ A method of obtaining rapid, accurate chemical and decontamination information should be included in regional disaster plans. ⁴ Regional poison centers play a pivotal role in disaster preparedness and response in relation to providing rapid, accurate chemical and decontamination information.^4,6,7,9,11 Similar to our analysis, Lehman-Huskamp et al argue that “[c]urrent literature regarding disasters or mass casualty incidents, especially those including hazmat or hazardous materials exposures, often suggests involving the regional poison center to assist with agent identification, to give decontamination suggestions, and to provide the subsequent medical management guidance once the agent is identified.” ⁹ Poison centers provide immediate accurate, unbiased information and guidance to manage identified risks ¹¹ and are widely used by EMS providers as one of the most commonly used resources for information on the identification of a chemical agent, treatment, and antidote. ⁶ EMS providers selected poison centers as the best resource for timely information, availability, and ease of contact. ⁶

Poison centers are staffed with registered nurses, pharmacists, physician assistants, physicians, and clinical and medical toxicologists ^2,14 who play an integral role in mitigating risks associated with disaster events. Having these experts in a poison center enhances the availability of rapid, reliable, and unbiased information to healthcare providers and victims; their involvement is crucial when mass administration of pharmaceuticals is needed in response to a disaster event, especially those involving chemical, radiological, or nuclear exposures or biological terrorism. ¹⁰ Toxicologists, in particular, play an important role in developing and managing syndromic surveillance, identifying clinical presentation in patients, producing datasheets, and managing MCM requisitions and stockpiles. ⁵

In addition to providing critical information and expert guidance to identified threats and the medical means by which to address them, poison centers also play a pivotal role in identifying emerging threats through their surveillance of call volumes and content. In their analysis, Vassilev et al found that “large-scale public health disasters, caused by both natural and human factors, may result in a drastic increase in the number of inquiries received and handled by poison centers in short periods of time.” ⁸ Accordingly, it is crucial that data are collected correctly, consistently, and quickly, especially under adverse conditions. ¹¹ The data collected by poison centers are valuable sources of information on exposures during a disaster ¹¹ as they can be used by emergency responders, planners, and policy decision makers to decide what type(s) of clinical or technical expertise is needed to manage disaster-related health threats. ¹¹ The data collected by poison centers are used to identify incidents of potential public health significance that can effectively mitigate public health risks. ¹⁶

The importance of integrating a poison center into the public health infrastructure ¹⁵ and its role in public health surveillance are increasingly recognized. ^{6-8,11,12,14,15} Public health surveillance, in general, is a mechanism through which data are collected and analyzed to help identify health problems, establish priorities, and target interventions to meet population needs. ¹¹ The data collected by poison centers provide data sources of chemical exposures and poisonings and contribute to the assessment of postdisaster health threats. ¹¹ Demand for poison center expertise will continue to increase during and after large-scale disasters, driven largely by the need for appropriate and constructive public information and an increase in the number of poisonings. ⁷ The investigation into the toxicity associated with laundry detergent pods ²⁶ provides a striking example of how poison center surveillance data have been integrated into the public health infrastructure and how the data were used to facilitate a change in laundry pod packaging to include safety information. ²⁷ Surveillance data also helped advocates to raise awareness of the need for regulation of sales and manufacturing of e-cigarettes. ²⁷

While all poison centers assist in the assessment and management of disaster risks, some have added nontraditional roles to their scope of services as they continue to find creative ways to form new partnerships and utilize their skills to mitigate disaster and other public health risks. For example, the Georgia Poison Center partnered with public health and safety agencies and performed extensive risk assessment and planning for the 1996 Olympic Games. ²⁸ Following the 2010 Gulf oil spill, the Louisiana Poison Center and other Gulf Coast poison centers played a key role in the disaster response by addressing callers' concerns about the health effects of the spill and providing expert guidance and surveillance data to state and federal partners. ²⁹ Poison centers have also played key roles in responding to concerns about food and water contamination, carbon monoxide, and other hazardous exposures encountered during hurricanes and power outages,^2,7 as well as concerns about outbreaks of measles,^30,31 fungal meningitis, ³² and the opioid crisis.^33,34

There is opportunity to expand collaborations between poison centers and public health agencies. A survey of poison centers and state and local health departments assessed partnerships and interactions between these entities and found a high level of variability among the collaborations. ³⁵ Although all of the poison centers in the study reported some interaction with health departments, nearly one-third (30.4%) of them reported only minimal contact. Likewise, a high level of interactivity with health departments was reported by only 34.8% of respondents. ³⁵ The authors concluded that sharing of best practices and enhanced collaboration between poison centers and health departments may improve the nation's public health. ³⁵

In order to enhance mutually beneficial partnerships with their poison centers, public health officials should consider inviting poison center leaders to become involved in public health planning coalitions so that the center's role in local and statewide CBRN/PH incident response and surveillance can be defined and/or expanded. Potential collaboration discussion topics could include: (1) defining the poison center's role in widespread incident notification and dissemination of clinical guidance, (2) assisting with the operation of public health hotlines, (3) formalizing the poison center's role in statewide CHEMPACK and other antidote stockpile requests, and (4) expanding data sharing and surveillance partnerships. If distance is not a barrier, a visit to the poison center can give public health partners the opportunity to learn firsthand about the center's specialized services and expertise.

From the NRPC's perspective, successful public health and other community partnerships often resulted from an openness to explore new service opportunities outside of traditional poison center roles. These opportunities presented themselves after the NRPC team became involved in disaster preparedness coalitions and developed relationships with public health colleagues by attending in-person planning meetings, participating in training sessions and disaster exercises, and delivering on promises to provide timely, helpful responses during actual events. In particular, NRPC leaders have found the following strategies to be successful when building relationships with public health and other community partners: (1) accept invitations and/or volunteer to participate in healthcare coalitions and other public health projects; (2) identify public health and other healthcare partner needs and volunteer poison center services to fill gaps, without asking for anything in return; and (3) develop personal relationships and establish trust with key partners by making themselves available to assist public health partners 24/7. When poison center leaders repeatedly sit across a planning table, reminding others of what they do and offering their assistance, they will be remembered and contacted when help is needed. As a result, those poison center leaders should expect to receive after-hours requests from public health colleagues and ensure that those requests will receive immediate attention. Once public health partners discover the many ways in which a poison center team can contribute, opportunities for poison centers to participate in funded projects and grant partnerships should follow.

Another step that both public health and poison centers can take to potentially enhance their partnerships is to join the Poison Center and Public Health Collaborations Community of Practice. ³⁶ The community of practice, which is open to all interested health department and poison center staff, was formed in 2010 to “bolster collaboration between federal, state, and local health agencies and departments and poison centers through sharing best practices and facilitating networking between members.” ³⁷ The knowledge gained by participating in the community of practice has been beneficial to NRPC and Nebraska DHHS staff as they continue to explore new collaboration ideas.

Conclusion

The critically important disaster health response-related assistance provided by the NRPC and its partnership with the OMHCC and the Nebraska DHHS is unique. The NRPC plays a key role in assessing and managing risk by coordinating and facilitating efforts to prepare for and respond to a variety of disaster incident types that range from routine hazardous materials incidents to larger, mass casualty CBRN/PH incidents. We detail the NRPC's capabilities and practices here and recommend it as a model to inform other poison center and public health partnerships across the United States. Through active participation, each partner can improve local, state, and regional public health response to routine hazardous materials and CBRN/PH incidents by supporting the management of public health/information hotlines and disaster and emergency medications within and across jurisdictions. We provide practical suggestions for how poison centers can engage with public health and other community partners and strategies to facilitate the sharing of surveillance data, expertise, and best practices through networking and collaborative efforts at the local, state, regional, and federal levels.