AMERICAN ASSOCIATION OF POISON CONTROL CENTERS INTRODUCTION Criteria for Certification of Poison Centers and Poison Center Systems Revised: July 29, 2005 The purpose of this document is to establish criteria by which Poison Centers and Poison Center Systems can be recognized as possessing the qualifications needed to adequately serve their designated population. Definitions: A Certified Poison Center is an organization which provides the following services to a region which it has been designated to serve: 1) poison information, telephone management advice and consultation about toxic exposures; 2) hazard surveillance to achieve hazard elimination; 3) professional and public education in poison prevention, diagnosis, and treatment; and 4) meets the AAPCC Criteria for Certification of Poison Centers and Poison Center Systems. A Certified Poison Center System a Poison Center System which consists of two or more Poison Centers serving a given region, all of which are functionally and electronically linked and which meet the AAPCC Criteria for Certification of Poison Centers and Poison Center Systems. There cannot be any state-designated non-certified centers in the region of a Certified System unless they are components of the System. Electronic linkage: A Poison Center System must have the technology in place to allow real-time computer-networked access through a shared or replicated database to patient records from any point within the system, with the capability to retrieve records, make charting entries, and return records to the system from any access point. Faxing is not sufficient evidence of real-time access. Functional linkage: A Poison Center System must provide evidence of coordinated patient care guidelines, which ensure a single standard of information and care, across the system. I. DETERMINATION OF REGION A. Geographical characteristics. A Certified Poison Center or System may serve a single state, a multi-state area, or only a portion of a state. The region
should be determined by state authorities in conjunction with local health agencies and health care providers. In instances where multiple states are involved, designation from each state is necessary. Documentation of state designations of Poison Centers and Systems must be in writing and must clearly delineate the region to be served, the services to be provided, and the exclusivity of the designation. In instances where a state declines in writing to designate any Poison Center or System, designation by other political or health jurisdictions (e.g., county, health district) may be an acceptable alternative. In instances where more than one Center or System is designated to serve the same area, evidence of cooperative arrangements must be provided. B. Population base. The Certified Poison Center or Poison Center System must provide evidence that it adequately serves its entire region. It is unlikely that a single Poison Center could adequately serve more than 10 million people. C. Penetrance. The penetrance of a Poison Center or System in a region is defined as the number of human poison exposure cases handled per 1000 population per year. Penetrance is assumed to be most affected by the public s awareness of the appropriate use of the Poison Center. A Certified Poison Center or System must demonstrate a minimum average penetrance of 7.0 throughout its service area. Poison Centers and Poison Center Systems should strive to achieve a penetrance of 12 to 15 throughout the region served, by increasing or maintaining awareness of Poison Center services. 1 II. REGIONAL POISON INFORMATION SERVICE A. The Certified Poison Center or System shall provide information 24 hours/day, 365 days/year to both health professionals and the public. This criterion will be considered to be met if the Certified Poison Center has at least one Specialist in Poison Information in each Center at all times, sufficient additional staff to promptly handle each Center's incoming calls, and has the availability of the medical director or qualified designee, on-call by telephone, at all times. Only if part of a System, Certified Poison Centers may divert calls to another Certified Poison Center within the same state, within a contiguous region, or to the closest Certified Poison Center, if: 1) unequivocal continuity of clinical care is achieved through functional access to all open patient records, and 2) the receiving Certified Poison Center staff are fully trained and informed about all health care, EMS, and lab facility capabilities and regional toxicology variations. (The criteria relating to diversion of calls, functional access to open patient records, and knowledge of facilities and regional toxicology variations do not apply when assisting another Poison Center in a disaster situation.) 1 On September 29, 2002, the AAPCC Board of Directors voted to suspend the pentrance criterion indefinitely. Until further notice, centers and systems need not provide penetrance data. 2
B. The Certified Poison Center or System shall be readily accessible by telephone from all areas within the region. 1. The Certified Poison Center or System must maintain a direct incoming telephone system that is extensively publicized throughout the region to both health professionals and the public. 2. The Certified Poison Center or System must maintain a telecommunications system adequate to assure ready access and must provide data verifying ready access. 3. The Certified Poison Center or System must ensure that the nationwide toll free number established by AAPCC (1-800-222-1222) works in its region as specified in the AAPCC Policy Statement of Acceptable Use. 4. A Certified Poison Center or System may not impose a direct fee to individual members of the lay public (either by direct billing or pay-for-call services) for poison exposure emergency calls received from the public within its region. 5. The Certified Poison Center or System must be able to respond to inquiries in languages other than English as appropriate to the region using language translation services, interpreters, and/or bilingual staff. 6. Access for hearing-impaired individuals must be provided. 7. A plan to provide Poison Center services in response to natural and technological disasters must be in place. C. The Certified Poison Center or System shall maintain comprehensive poison information resources (at each site). This criterion will be considered to be met if each Center maintains: 1. One or more comprehensive product information resources, immediately available to the Specialist in Poison Information at all times. 2. Current comprehensive references covering both general and specific aspects of acute and chronic poisoning management immediately available to the Specialist in Poison Information at all times. There must be access to the most current primary information resources and ready availability of a major medical library or comparable on-line resources. 3. Evidence of the competency of all specialists and information providers in using texts, information resources, and primary literature. 3
D. The Certified Poison Center or System shall maintain written operational guidelines which provide a consistent approach to evaluation and management of toxic exposures. This criterion will be considered to be met if the Certified Poison Center or System provides written operational guidelines which include but are not limited to the follow-up of all potentially toxic exposures and appropriate criteria for patient disposition. These guidelines must be available in the Center at all times and must be approved in writing by the medical director of the program. In addition, these guidelines must have evidence of periodic review, and the Center must provide evidence of action taken to remedy problems with guideline content or guideline adherence through quality assurance programs and staff education. E. Staffing requirements and qualifications for the Certified Poison Center or System. 1. Toxicological supervision. Certified Poison Centers and each Center within a Certified Poison Center System must provide full-time toxicological supervision. This must include at least one full-time equivalent of on-site toxicological supervision and appropriate back-up. These components must meet the specific criteria listed below. Each site of a Certified Poison Center System must meet the requirements for Medical and Managing direction. A) Medical direction and medical back-up. 1) Medical direction may be provided by a single Medical Director or by more than one individual. If more than one individual provides medical direction, one individual must be designated as Medical Director and that person is responsible for approving other individuals involved and for coordinating their activities. 2) The medical director and all other individuals designated as providers of medical direction must be board certified in medical toxicology or boardprepared in medical toxicology as determined by a letter from the Board indicating that the candidate will be allowed to sit for the next examination. Following completion of training a medical director may qualify as board prepared for a period of six years or three opportunities to sit for the exam. Board certification is through either the American Board of Medical Toxicology (pre- 1994) or through the American Board of Medical Specialties subspecialty exam in medical toxicology (after 1994) is acceptable. Doctors of Osteopathy may serve as medical directors of certified poison centers or poison center systems if they have completed a two year ACGME-approved fellowship and have passed the American Osteopathic Board of Emergency Medicine examination for Certification of
Added Qualification in Medical Toxicology. Physicians without board certification in medical toxicology will be considered qualified as Medical Directors for the purpose of determining compliance with the current criteria if: 1) the physician served as Medical Director of a Poison Center certified by AAPCC as of September 14, 1998; and 2) the physician met the immediately previous AAPCC criteria for Medical Directors on September 14, 1998. 3) The Medical Director and all other individuals designated as providers of medical direction must have medical staff appointments at an inpatient treatment facility, must be involved in the management of poisoned patients, and must regularly consult with Specialists in Poison Information about the management of poisoned patients. 4) The individual or individuals providing medical direction must individually or collectively devote at least 20 hours per week of professional activity time to toxicology. An additional 10 hours per week of medical direction time must be provided for each 25,000 human poison exposure cases per year received by the Certified Poison Center, above the initial 25,000 human poison exposure cases. Time applied to this total should conform to the following standards: a. Up to 10 hours per week of the total time applied to medical direction may consist of toxicology activities not directly related to Certified Poison Center operation, such as clinical, academic, teaching, and research activities. No more than 10 percent of clinical time in emergency department, clinic, ward, or intensive care unit service will apply to this total, unless specific documentation is provided to verify that the additional time was directly related to toxicology. b. The remainder of the total time applied to medical direction activities must consist of Poison Center operational activities during the time that is 100 percent dedicated to on-site medical direction at each Certified Poison Center or site of a Poison Center System. This may consist of aggregate day by day attendance, a single 8 hour day/week for physicians traveling to the center, or video conferencing directly accessible to the Specialists in Poison Information with 2 hours satisfying the equivalent of 1 hour on site. These may be combined within any month to satisfy the overall requirement. Video conferencing may not satisfy more than 50% of the total requirement. The following table represents the minimum time commitments for medical direction. Additional medical direction is desirable and may be
necessary. # human poison exposures/year 100 % PC hours Total tox hours 25,000 10 20 50,000 20 30 75,000 30 40 100,000 40 50 125,000 50 60 5) Medical backup must be available, in a timely manner, at all times. If not provided by the Medical Director, medical backup may be provided by those providing medical direction or other individuals designated by the Medical Director. All medical backup must be provided by board-certified or board-prepared medical toxicologists. Other individuals identified and qualified by the Medical Director (e.g. fellows, Managing Director) may serve as immediate Certified Poison Center backup if timely secondary backup is provided at all times by a board-certified or board-prepared medical toxicologist. Direct clinical effort as backup can be applied to item 4.A. above. 6) A medical director of a certified poison control center must be licensed in the state where the center is located, and must spend a minimum of 10 hours per week physically in the exclusive service area served by his/her poison control center. B) Managing direction. 1) The Managing Director provides direct toxicological supervision of Poison Center staff, strategic planning, and oversight of administrative functions of programs, e.g. staff training, quality assurance, budgeting, etc. 2) Managing direction may be provided by a single Managing Director or may be provided by more than one individual, each with the qualifications identified below. If more than one individual is involved in providing managing direction, one individual must be designated as Managing Director (or comparable title), and that person is responsible for coordinating managing direction activities. 3) The Managing Director must be a nurse with a baccalaureate degree,
associate degree, or three-year diploma; pharmacist; physician; or may hold a degree in a life science discipline if a diplomate of the American Board of Applied Toxicology. If the Managing Director is also the Medical Director, this person must have a full time commitment to the Poison Center. 4) The Managing Director with toxicological supervision responsibilities must be board certified or board prepared, as evidenced by a letter from the appropriate board indicating that the candidate will be allowed to sit for the next examination. For physicians this Board can be the ABMT (pre- 1994) or the ABMS subspecialty examination in medical toxicology (post- 1994). For all others, the board must be the American Board of Applied Toxicology. Candidates for the board examination must successfully complete the examination within three consecutive administrations of the examination. Individuals without board certification in applied toxicology will be considered qualified as Managing Directors for the purpose of determining compliance with the current criteria if: 1) the individual served as Managing Director of a Poison Center certified by AAPCC as of September 14, 1998; and 2) the individual met the immediately previous AAPCC criteria for Managing Directors on September 14, 1998. 2. Specialists in Poison Information. A Specialist in Poison Information must be on duty in the Certified Poison Center, or at each functioning site of a Poison Center System, at all times. A) Specialists in Poison Information must be 1) a nurse with a baccalaureate degree, associate degree, or three-year diploma; pharmacist; or physician; or 2) currently certified by AAPCC as a Specialist in Poison Information; or 3) nationally certified physician assistant (PA-C); or 4) a diplomate of the American Board of Applied Toxicology; or 5) a board-certified medical toxicologist. Specialists in Poison Information must be qualified to understand and interpret standard poison information resources and to transmit that information in a logical, concise, and understandable way to both health professionals and the public. B) All Specialists in Poison Information must complete a training program approved by the Medical Director and, unless a diplomate of the American Board of Applied Toxicology or a board-certified medical toxicologist, must be certified by AAPCC as a Specialist in Poison Information within three examination administrations of his or her initial eligibility for certification. If a Specialist in Poison Information fails to pass a certification exam within three exam administrations of his or her initial eligibility for certification, he or she
may work only as a Poison Information Provider under direction as described in Section II.E.3. If an individual fails a recertification examination or does not take a recertification examination, that person reverts to the position of Specialist in Poison Information. C) Specialists in Poison Information not currently certified by AAPCC as Specialists in Poison information must spend an annual average of no fewer than 16 hours per week in Poison Center related activities, including providing telephone consultation, teaching, public education, or in Poison Center operations. Specialists in Poison Information currently certified by AAPCC as Specialists in Poison Information must spend an annual average of no fewer than 8 hours per week in Poison Center related activities, including providing telephone consultation, teaching, public education, or in Poison Center operations. Individuals who do not meet this criterion may work as Poison Information Providers with direction as described in II.E.3. D) All Specialists in Poison Information, whether full-time or part-time, must be 100% dedicated to Poison Center activities during periods when they are assigned to the Center. Poison Center calls must be their first priority. In cases where a Poison Center assumes other roles, the Center must demonstrate policies and safeguards that assure that Poison Center calls are given priority and that these other activities pose no conflict with poison exposure cases and cause no reduction of service quality or quantity within the Certified Poison Center s region. E) At the time of initial application for Poison Center certification and thereafter, at least 50% of Specialist in Poison Information full time equivalent positions (FTE s) must be filled by Certified Specialists in Poison Information. For Certified Poison Center Systems, at least 50% of Specialists in Poison Information FTE's at each site must be Certified Specialists in Poison Information. F) To maintain experience and expertise, on average each Certified Poison Center must handle at least 2,000 human poison exposures per SPI/PIP full time equivalent. 3. Other poison information providers. Other poison information providers must be qualified to understand and interpret standard poison information resources and to transmit that information understandably to both health professionals and the public. This requirement will be considered to be met if the person has an appropriate health-oriented background and has specific training and/or experience in poison information sciences. While they may be part-time staff or have a part-time commitment to the Poison Center, 100% of their time should be dedicated to Poison Center activities while assigned to the
Center. At all times, poison information providers must be under the on-site direction of a Certified Specialist in Poison Information, a qualified Managing Director, or the Medical Director; these individuals may provide direction for no more than two poison information providers at one time. 4. Certified Poison Center specialty consultants. Certified Poison Center specialty consultants should be qualified by training or experience to provide sophisticated toxicology or patient care information in their area(s) of expertise. These consultants should be available on-call and provide consultation on-call on an as-needed basis. The list of consultants should reflect the type of poisonings encountered in the region. 5. Administrative staff. Certified Poison Center administrative personnel should be qualified by training and/or experience to supervise finances, operations, personnel, data analysis, and other administrative functions of the Certified Poison Center. 6. Education Staff. A) Professional education. Professional education personnel should be qualified by training or experience to provide quality professional education lectures or materials to health professionals. This role will be supervised by the Medical Director. B) Public education. Public education personnel should have proven skills in communication and program planning, implementation, and evaluation, and/or an appropriate educational background with which to provide publicoriented presentations about Poison Center awareness and the value of the Poison Center, poison prevention and first aid for poisoning. This role will be supervised by the Medical and/or Managing Director. F. The Certified Poison Center or System shall have an ongoing quality improvement program. 1. A Certified Poison Center or System shall implement quality assurance activities which incorporate specific monitoring parameters and staff education programs. 2. A Certified Poison Center or System shall demonstrate that patient outcomes are monitored regarding high risk, high volume, or problem-prone cases. The corrective actions taken to improve patient care shall be documented. In addition, the Certified Poison Center should demonstrate monitoring of customer satisfaction and assessment of staff competency.
III. REGIONAL TREATMENT CAPABILITIES The Certified Poison Center or System shall identify the treatment capabilities of the treatment facilities of the region. At a minimum, the Certified Poison Center or System should: identify emergency and critical care treatment capabilities within the region for adults and children; have a working relationship with all poison treatment facilities in its region; understand the analytical toxicology facilities in the region and how to interface with them; understand how the region s prehospital transportation system is structured and how to interface with it; know where critical antidotes are available within the region and how they can be transferred between facilities when necessary. IV. DATA COLLECTION SYSTEM A. The Certified Poison Center or System shall keep records of all cases handled by the Center in a form that is acceptable as a medical record. This criterion will be considered to be met if the Center completes a record that contains data elements and sufficient narrative to allow for peer review and medical and/or legal audit, and such records are retrievable. B. The Certified Poison Center or System must submit all its human exposure data (except as noted in IV.B.1.) to AAPCC's Toxic Exposure Surveillance System meeting specified submission deadlines and quality requirements and including all required data elements. 1. The submission of human exposure data derived from industry contracts is encouraged but not required for certification. 2. Certified Poison Centers that withhold industry-derived human exposure data must annually submit the number of industry-derived human exposures that were withheld. C. The Certified Poison Center or System shall tabulate its experience for regional program evaluation and hazard surveillance on at least an annual basis. This criterion will be considered to be met if the Center completes an annual report summarizing its own experience. D. The Certified Poison Center shall monitor the emergence of poisoning hazards and take specific actions to eliminate poisoning hazards. V. PROFESSIONAL AND PUBLIC EDUCATION PROGRAMS A. The Certified Poison Center or System shall provide information on the management of poisoning to the health professionals throughout the region
who care for poisoned patients. This criterion will be considered to be met if the Certified Poison Center offers on-going information about Poison Center access and services and updates on new and important advances in poisoning management to the health professionals throughout the region. B. The Certified Poison Center or System shall provide a variety of public education activities targeting identified "at-risk" populations. The programs shall address poisoning dangers, poison prevention strategies, first aid for poisoning, and when and how to access Poison Center services. These programs must be implemented throughout the Certified Poison Center's region. VI. ASSOCIATION MEMBERSHIP The applicant Poison Center and each site in a Poison Center System must be an institutional member in good standing of the American Association of Poison Control Centers. (Approved April 1988 by the AAPCC Board of Directors. Amended October 1991; September 1992; January 1996.; September 14, 1998; October 1, 2001; October 6, 2001; July 8, 2002; September 28, 2002; April 19, 2005; July 29, 2005.)