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CLINICAL
TOXICOLOGY UNIT
Princess Alexandra Hospital
2015 Annual Report
2
Table of Contents
Page
Executive Summary
4
Section 1: Service Data
Clinical Toxicology Unit staffing levels
6
Activities
6
Yearly presentations 2014-2015
7
2015 Monthly presentations
8
Presentations by age and gender
9
Patient flow management
11
Length of Stay 2015
14
Prescription Drug Presentations
17
Recreational Drug presentations
19
Bites and envenomations
20
Section 2: Research and Educational Activities 2011-2015
Research – Publications
21
Research – Conference presentations
24
Research – Conference posters
25
Book Chapters/Sections
26
Reviews for Journals
27
Educational Activities/Presentations/Course Instructor
28
3
Executive Summary
The Clinical Toxicology Unit (CTOX) was established at the Princess Alexandra Hospital
(PAH) in February 2014, and is the first of its kind in Queensland. It has just completed
its first full calendar year of operation providing inpatient management, and advice on
patients suffering from the effects of prescription and recreational drugs taken
therapeutically, accidentally or in overdose. It also provides crucial toxinology advice
regarding the management of patients with stings and bites, including snake bite
envenomation. In addition, it provides an informal consultation service to other hospitals
within South East Queensland who are aware of the unit.
The aim of the service is to coordinate & improve the quality of care of the toxicological
patient with an emphasis on reducing length of stay while maintaining high quality
evidence based medicine. It commenced with no funding and a registrar borrowed from
the Department of Emergency Medicine (DEM) and its results are remarkable when
benchmarked against other hospitals based on Health Round Table (HRT) data over the
last five years.
Achievements:
1. In 2015 the unit managed 1787 patients with a median length of stay of 11.5 hours.
2. Relative length of stay index in 2015 based on HRT data of 56% (133% prior to the
unit’s commencement).
3. Number 1 in beds saved at PAH in 2014 & 2015 with 1400 bed days saved over this 2year period again based on HRT data.
4. Nominee for the 2015 Metro South heath Board Chair’s Award “ideas into action”
In addition to its clinical success, the CTOX unit has now achieved funding to the level of
1.0 FTE through the PAH and the Lady Cilento Children’s Hospital (LCCH). This goes
part way to providing a financial basis for the unit’s continual operation. Formal links
through the establishment of a medical director position with the Queensland Poisons
Information Centre (QPIC) based at the LCCH has been negotiated with this funding.
Accreditation has also been approved for registrar training as a special skills term in
Toxicology with the Australasian College for Emergency Medicine.
4
Research continues to be a major priority of the unit’s activity and 2015 has seen the
publication of two large studies examining the safety of droperidol in acute behavioural
disturbance and the safety of a new regimen of N-acetylcysteine, the antidote used in
paracetamol toxicity. The Australian TOxicology Monitoring (ATOM) Study commenced in
2014 will be the cornerstone of future toxicological research at PAH and in Queensland
examining drug toxicity with laboratory confirmation of serum drug levels and markers of
drug toxicity.
In 2016, the CTOX unit will commence training of a second toxicologist and the teaching
and research will continue to grow as we expand our workforce. A formal, advertised
consultation service for the Metro South Hospital & Health Service will be established
and plans will commence on moving the QPIC to the PAH.
Lastly the success of the unit over the last 2 years could not have been achieved without
the support of my emergency department colleagues and the director of the DEM Dr Phil
Kay. My thanks also to the department of general medicine in particular Professor’s Peter
Pillans and Ian Scott whose support has been critical not only to the formation of the unit
but its ongoing role within the hospital.
Dr Colin Page
MBChB FACEM MMedSci (Clin Epid)
Clinical Toxicologist
Director of Clinical Toxicology & Medical Director QPIC
5
Service Data
Clinical Toxicology Unit staffing
Physician/Director – Dr Colin Page (0.5 FTE)
Clinical Toxicology Fellow – Dr Katherine Isoardi (Commencing February 2016)
Registrars
ED – 1.0 FTE post-exam ACEM Advanced trainee
Melanie Armitage (Jan-July) Julia Kelly (Aug–Jan)
Ward – Dr Sivarajah Ilango (Internal Medicine trainee)
Nursing
Dale Mason - CNC ED Short Stay Ward
Ian Ross – CNC Ward 5A
Administration – Jillian Vernon – Office Manager
Activities
•
Seven days a week ward rounds of toxicology patients in ED, ED short stay ward, Intensive
Care & wards.
•
Database of unit’s activities (Filemaker relational database)
•
Monthly unit meetings – Unit activity & audit (length of stay, NEAT compliance), case
presentations, journal club, research & 6 monthly morbidity and mortality.
•
Regular presentations at PAH ED teaching program
•
Medical Grand Rounds
•
Presentations at other Brisbane ED’s
•
QPIC toxicology consultant calls
•
QPIC continuing medical education meetings
6
Yearly Presentations 2014 - 2015
Yearlypresentations
2000
1800
1600
Numberofpatients
1400
1200
1000
1787
800
600
400
924
200
0
2014(May-Dec)
2015
Year
7
2015 Monthly Presentations
Presentationsbymonth
200
180
160
Numberofpatients
140
120
100
179
80
60
183
174
149
160
126
136
126
154
143
129
127
40
20
0
8
Presentations by Age and Gender
PresentationsbyGender
Female
49%
Male
51%
9
PresentationsbyAge&Gender
600
525
500
447
Numberofpatients
400
348
300
235
208
200
197
181
150
290
100
106
239
92
77
167
91
58
35
42
0
<20
20-29
30-39
Male
40-49
Age(years)
Female
50-59
60-69
43
23
20
≥70
Total
10
Patient Flow Management
AdmissionLocation
1.73% 0.39%
3.70%
0.22%
6.80%
22.60%
67.90%
RemaininED
ShortStayWardadmission
Admittedbyotherteam
ICUadmission
Consult
Mentalhealthadmission
TransferredtoLCCH
11
SSWDisposition
1.10%
1.50%
16.20%
0.42%
81.50%
Discharged
Ctoxward
MentalHealthAdmission
ICU
Otherinpatientteamadmission
12
AllPatientsAinaldisposition
0.29% 2.60%
14.40%
82.70%
MHfacility
Discharged
Died
CorrectionalServices
13
Length of stay 2015
MedianLengthofstaybymonth2015
16
14
Lengthofstay(hours)
12
10
8
14.7
12.6
6
10.8
9.6
4
12.1
11.6
9.3
10.6
10.6
11.5
10.5
9.7
8.6
2
0
14
TrendofRelativeStayIndexovertime
160
140
RelativeStayIndex(%)
120
100
80
60
40
20
0
2010-2011
2011-2012
2012-2013
2013-2014
2014-2015
FinancialYear
PAH
AllHRT
15
TrendofAverageLengthofStayovertime
2.5
Averagelengthofstay(days)
2
1.5
1
0.5
0
2010-2011
2011-2012
2012-2013
2013-2014
2014-2015
FinancialYear
PAH
AllHRT
16
Prescription Drug Presentations
MostCommonPrescriptionDrugPresentations
350
300
Numberofpresentations
250
200
322
310
150
100
152
50
144
96
81
62
72
60
0
17
PresentationsbyClassofDrug
13%
26%
15%
17%
29%
non-opiateanalgesics(paracetamol/NSAIDs/tramadol)
Benzodiazepines
Opioids(excludingheroin)
Antidepressants
Antipsychotics
18
Recreational Drug Presentations
PresentionsbyRecreationalDrug
250
Numberofpresenations
200
150
100
50
0
113
226
69
42
23
17
6
110
19
Bites and Envenomations
BiteandEnvenomationPresentations
20
18
16
Numberofpresentations
14
12
10
8
6
4
2
0
Spiderbite
Marinesting
Unknown
Snake-
Snake-no
envenomation envenomation
20
Research and Educational Activities
Research - Publications 2011-2015
Armitage MC, Woolfield KI, Page CB. Serotonin toxicity caused by the interaction of
fentanyl and serotonergic medications. Emergency Medicine Australasia. 2015 Dec 17.
Early on line
Isbister GK, Downes MA, McNamara K, Berling I, Whyte IM, Page CB. A prospective
observational study of a novel 2-phase infusion protocol for the administration of
acetylcysteine in paracetamol poisoning. Clin Toxicology 2015 Dec 22:1-7. Early on line
Bateman DN, Page CB. Antidotes to coumarins, isoniazid, methotrexate and thyroxine,
toxins that work via metabolic processes. BJCP 2015 early on line
Isbister GK, Page CB. Brown snake envenoming: Why are we left in the dark? Clin
Toxicology 2015 Nov;53(9):925
Calver L. Page CB, Downes M, Chan B, Kinnear F, Wheatley L, Spain D Isbister GK.
The Safety and Effectiveness of Droperidol for Sedation of Acute Behavioral Disturbance
in the Emergency Department. Annals of Emergency Medicine 2015 Vol. 66, Issue 3,
p230–238.e1
Letter to above – in reply Isbister GK, Calver L, Downes MA, Page CB. Ann Emerg Med.
2016 Jan;67(1):146-7.
Calver L, Drinkwater V, Gupta R, Page CB & Isbister GK. Droperidol v. haloperidol for
sedation of aggressive behaviour in acute mental health: randomised controlled trial. Br J
Psychiatry. 2015 Mar;206(3):223-8.
Isbister GK, Maduwage K & Page CB. Antivenom cross neutralisation in a suspected
Asian pit viper envenoming causing severe coagulopathy. Toxicon 2014;90:286-90
Williams MM, Taylor PJ, Page CB & Martin JH. Clinical research in synthetic
cannabinoids — do we need a national approach. MJA 2014;201(6): 1-3
21
Isbister GK, Page CB, Buckley NA, Fatovich Dm. Pascu O, MacDonald SPJ, Calver LA &
Brown SGA. Randomized Controlled Trial of Intravenous Antivenom Versus Placebo for
Latrodectism: The Second Redback Antivenom Evaluation (RAVE-II) Study. Annals of
Emergency Medicine 2014, Vol. 64, Issue 6, p620–628.e2
Letter to above – in reply Geoffrey K. Isbister, Colin B. Page, Nicholas A. Buckley, Daniel
M. Fatovich, Simon G.A. Brown. Annals of Emergency Medicine, Vol. 65, Issue 1, p124–
125
Dimeski G, Jones B, Pillans P, Page C, Brown NN. Digoxin overdose - an accurate
method for determining free digoxin concentrations on general chemistry analysers post
DigiFab treatment. Clin Chem Lab Med. 2014 Feb 24.
Isbister GK, Buckley NA, Page CB et al. Snakebite in Australia: a practical approach to
diagnosis and treatment. MJA 2013;199(11): 763-8
Isbister GK, Buckley NA, Page CB et al. A randomized controlled trial of fresh frozen
plasma for treating venom-induced consumption coagulopathy in cases of Australian
snakebite (ASP-18). Journal of Thrombosis & Haemostasis 2013 Jul; 11: 1310-18
Isbister GK, Page CB. Drug induced QT prolongation: the measurement and assessment
of QT interval in clinical practice. BJCP 2013 Jul;76(1) 48-57
Parker SD, De Gioannis A & Page C. Chronic promethazine misuse and the possibility of
dependence: a brief review of antihistamine abuse and dependence. Journal of
Substance Use 2013;18(3): 238-41
Allen GE, Brown SGA, Buckley NA, O’Leary MA, Page CB, et al. Clinical Effects and
Antivenom Dosing in Brown Snake (Pseudonaja spp.) Envenoming — Australian
Snakebite Project (ASP-14). PLoS ONE 2012 7(12): e53188.
Isbister GK, Page CB. Earlier endoscopy or CT in caustic injuries: A re-evaluation of
clinical practice. Clinical Toxicology 2011;49:641-1
22
Page CB, Wilson PA, Foy A, Downes MA, Whyte IM & Isbister GK. Life-threatening
hypokalaemia associated with ibuprofen- induced renal tubular acidosis. MJA 2011;194:
613-4
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Research – Conference Presentations 2011-2015
Vlad I, Page C, Brown J & Cairns R. Jungle Juice or When Oxygen Does not Turn Blue
into Red. TAPNA 2015
Page C. Toxicology Knicks Knacks. The new NAC. A novel infusion protocol for the
administration of N-acetyl cysteine. Autumn Symposium (Queensland ACEM) May 2014
Chiew A & Page C. Just another paracetamol overdose. TAPNA 2014
McNamara KP, Sellors K, Isbister GK, Whyte IM, Page C, Downes M. Death following
recreational use of alph-pyrrolidinopentophenone (alpha PVP): A case of excited delirium
syndrome. TAPNA May 2013
McNamara KP, Isbister GK, Whyte IM, Page CB, Downes M. Sustained release
paracetamol toxicity: A case of kinetics. TAPNA May 2013
Dean D, Wylie C & Page C. A bite to remember. A case report of a snakebite
envenoming. TAPNA May 2013.
Isbister GK, Buckley NA, Page CB, Scorgie FE, Lincz LF, Seldon M, Brown SGA for the
ASP Investigators. A randomised controlled trial of fresh frozen plasma for venom
induced consumption coagulopathy in Australian snakebite (ASP-18) – Abstract APAMT
meeting Nov 2012
24
Research – Conference Posters 2011 – 2015
Isbister G, Downes M, McNamara K, Berling I, Whyte I, Page C. A novel infusion protocol
for the administration of acetylcysteine. EAPCCT Malta May 2015
Page CB, Mostafa A, Saiao A, Grice J, Roberts M, Isbister GK. Cardiovascular Toxicity
with Levetiracetam Overdose. EAPCCT Malta May 2015
Isbister GK, Buckley NA, Page CB, Brown SGA. A multicentre cohort study of snake
envenoming defines clinical syndromes and influences clinical practice?. EAPCTT Malta
May 2015
Page C, Berling I & Isbister G. Rate dependent bundle branch block in drug overdose a
case report. TAPNA 2014.
Calver LA, Downes MA, Page CB, Chan B & Isbister GK. Droperidol for sedation of acute
behavioural disturbance. ASEM meeting May 2012 Chicago.
Calver LA, Downes MA, Page CB, Chan B & Isbister GK. Safety of droperidol for
sedation of acute behavioural disturbance. ASEM meeting May 2012 Chicago.
25
Book Chapters/Sections
Oxford textbook of Critical Care 4th ed 2016. Poisoning – Beta Blockers and Calcium
channel Blockers. Co authored with Geoff Isbister.
Queensland Health and Royal Flying Doctor Service (Queensland Section), Primary
Clinical Care Manual 9th edition 2015. Poisoning and drug emergencies and toxinology
chapters. Co authored with Carol Wylie – Manager Queensland Poisons Information
Centre.
Queensland Health and Royal Flying Doctor Service (Queensland Section), Primary
Clinical Care Manual 8th edition 2013. Poisoning and drug emergencies and toxinology
chapters. Co authored with Carol Wylie – Manager Queensland Poisons Information
Centre.
RBH prescribing guidelines – toxicology section 2011 & 2013
Queensland Health and Royal Flying Doctor Service (Queensland Section), Primary
Clinical Care Manual 7th edition 2011. Poisoning and drug emergencies and toxinology
chapters. Co authored with Carol Wylie – Manager Queensland Poisons Information
Centre.
PAH prescribing guidelines – toxicology section 2011
Section Editor – Toxicology – Emergency Medicine Australasia (2013-)
26
Reviews for Journals
Annals of Pharmacotherapy
Human & Experimental Toxicology
Journal of Clinical Psychopharmacology
Emergency Medicine Australasia
Emergency Medicine Journal
General Hospital Psychiatry
Medical Journal of Australia
Australian Prescriber
Neuropsychiatric Disease and Treatment
CNS Drugs
European Journal of Emergency Medicine
Journal of the Neurological Sciences
27
Educational Activities/Presentations/Course Instructor
2011-2015
TPCH – Consultant CME November 2015 – Paracetamol guidelines 2015
PAH Grand Rounds November 2015 – Haemodialysis in Lithium toxicity
LCCH – Consultant CME August 2015 – Paracetamol guidelines 2015
PAH Grand Rounds June 2015 - Acute Digoxin Toxicity
ACEM QLD Autumn Symposium 2015 – Toxicology workshop
TAPNA - Toxicology course (1 day) May 2015
Redcliffe Emergency Department teaching May 2015 – QT Interval
Redcliffe Hospital Grand Rounds – May 2015 The NAC study
PAH Grand Rounds November 2014 – Tricyclic antidepressant overdose
Haematology special interest group – Haematologist and snakebite October 2014
Logan Hospital Grand Rounds October 2014 - Making sense of the QT interval in drug
overdose
RCH Grand Rounds September 2014 - Making sense of the QT interval in drug overdose
QE2 Hospital Nurse Practitioner teaching August 2014. Acute behavioural disturbance in
the ED
Toxicology update – College of Intensive Care Meeting Brisbane June 2014
28
PAH Grand Rounds June 2014 – Making sense of the QT interval in drug overdose
TAPNA - Toxicology course May 2014
TAPNA – Metabology workshop May 2014
PAH Haematology meeting – Haematologist and snakebite March 2014
QE2 Hospital ED teaching meeting March 2014. Acute behavioural disturbance in the ED
PAH Grand Rounds November 2103 – Acute behavioural disturbance in the ED
Logan Hospital ED training meeting July 2013. Acute behavioural disturbance in the ED
PAH Grand Rounds June 2013 – Insulin overdose
TAPNA Sedation of the agitated patient workshop presenter May 2013
Royal Brisbane & Woman’s Hospital November 2012 – Sedation of the agitated patient
Toxicology Course November 2012 - Sydney
PAH Grand Rounds November 2012 – Paracetamol toxicity
London Air Ambulance November 2012 – Droperidol for the sedation of the agitated
patient
TPCH Grand Rounds November 2012 – Sedation of the agitated patient
Society of Hospital Pharmacists of Australia Seminar in Emergency Medicine – Presenter
-September 2012
Newcastle toxicology course (1 day course) May 2012
NSW PIC Toxicology Meeting (2 day meeting) – Presenter April 2012
29
RPA Toxicology Course (1 day course) December 2011
PA Hospital Grand Rounds September 2011
Autumn Symposium (Queensland ACEM) – Management of the behavioural disturbed
patient. May 2011
30