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Report on the Texas Poison Control Network

VIEWS: 19 PAGES: 62

									Commission on State Emergency
Communications Report




Report on the Texas Poison
Control Network




                                February 2011
                                                              TABLE OF CONTENTS



        EXECUTIVE SUMMARY ................................................................................................................... 2

        BACKGROUND.................................................................................................................................. 3

        CURRENT STATUS............................................................................................................................ 5

            STATUTORY FRAMEWORK................................................................................................................ 5

            MAP OF THE TEXAS POISON CONTROL NETWORK REGIONS ................................................................ 7

            CURRENT STRUCTURE .................................................................................................................... 8

        ASSUMPTIONS................................................................................................................................ 11

            ASSUMPTION 1 – MAINTAIN CURRENT LEVEL OF SERVICE ................................................................ 11
            ASSUMPTION 2 – MAINTAIN ACCREDITATION FROM AMERICAN ASSOCIATION OF POISON CENTERS ..... 11
        EVALUATION OF OPTIONS FOR THE STRUCTURE OF THE TPCN .................................................. 12

            OPTION 1 – CONSOLIDATE SIX CENTERS INTO ONE ......................................................................... 12
            OPTION 2 – CONSOLIDATE SIX CENTERS INTO THREE ...................................................................... 14
            OPTION 3 – MAINTAIN SIX CENTERS AND INCREASE EFFICIENCY ...................................................... 15
        RECOMMENDATION........................................................................................................................ 17

        APPENDICES .................................................................................................................................. 18
                A.ACCREDITATION REQUIREMENTS ........................................................................................... 19

                B.HOST INSTITUTION SUPPORT ................................................................................................. 21

                C.MODELS OF CONSOLIDATION; COST AND STAFFING NEEDS FOR REMOTE AGENTS                                               .................... 23
                D.REGIONALITY ....................................................................................................................... 26

                E.NEEDS OF ENTITIES USING POISON CENTER SERVICES ...........................................................                              29
                F.STAFFING ............................................................................................................................   33
                G.EXPERIENCE OF NEW YORK AND CALIFORNIA STATE POISON PROGRAMS                                           ................................ 35
                H.IMPACT OF PROPOSED FY 2012-2013 APPROPRIATION..........................................................                                 36
        ATTACHMENTS

                    A. HOST INSTITUTION LETTERS OF SUPPORT




CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                                                                               1
        EXECUTIVE SUMMARY
        As required in the Sunset Advisory Commission’s report on the Commission on State
        Emergency Communications (CSEC), the agency has conducted an evaluation of the Texas
        Poison Control Network’s (TPCN) current structure to determine any necessary changes, and
        report its findings to the 82nd Legislature. In its evaluation, the CSEC explored three options for
        the structure of the TPCN – (1) consolidate from six to one center; (2) consolidate from six to
        three centers; and, (3) maintain the current six-center structure.

        The CSEC recommends maintaining the current six-center structure with extensive latitude to
        standardize the network and bring efficiency to its function. This option builds on the strengths
        of the current system, and allows efficiencies to be found which will result in savings over time.
        To implement the CSEC recommendation, the statutory language in Health and Safety Code,
        Chapter 777 would need to be changed to be permissive as to the locations of the Poison
        Center sites. CSEC would need delegated authority and latitude to implement the required
        management and efficiency controls, and CSEC would be required to develop a plan and
        reasonable timeline for implementing the changes.

        In conducting its evaluation of alternative structures, the CSEC made two basic assumptions.
        Current levels of service should be maintained, which is consistent with the CSEC’s mission to
        preserve and enhance public safety and health in Texas through reliable access to emergency
        communications services. Accreditation from the American Association of Poison Control
        Centers (AAPCC) should be maintained, which is critical in providing assurance of quality
        medical oversight, and which is vital to maintaining the ability of the Poison Centers to receive
        non-supplanting federal funds from the Health Resources and Services Administration.

        While the one center and three center consolidation options would reduce some costs, the
        CSEC analysis found that each of these alternatives presented issues that would require
        additional resources to implement and jeopardize AAPCC certification. The six-center model
        eliminates costs associated with reconfiguring the network and maintains AAPCC certification,
        but it presents other challenges. Most significantly, the six-center model can be continued at
        the proposed FY 2012-13 funding levels, but not all poison center services that are provided
        today could be continued.

        The individuals who manage, operate, and staff each Poison Center within the TPCN are
        professionals strongly committed to health care service delivery and poison prevention.
        Through this strong commitment and collaboration, the CSEC and the Poison Centers can
        reorganize the TPCN to operate more efficiently and effectively to meet the needs of Texas.




CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                         2
        BACKGROUND
        As required by recommendation 2.2 of the Sunset Staff Report, as adopted,             the
        Commission on State Emergency Communications (CSEC) has conducted                      an
        evaluation of the Texas Poison Control Network (TPCN). While conducting               the
        evaluation, the CSEC considered the factors and data that are contained in            the
        appendices, and summarized below:

           •   The American Association of Poison Control Centers certification and
               accreditation requirements and staffing guidelines. Detail in Appendix A.

           •   The support and resources the host institutions provide, including indirect costs,
               staff training and education, and other in-kind contributions. Detail in Appendix
               B.

           •   Costs related to consolidating centers, such as the possible need for larger
               facilities to accommodate additional call takers and operational expenses the
               host institutions may not provide. Detail in Appendix C.

           •   Regional differences throughout the state, including available resources, and
               varying populations and potential hazards. Detail in Appendix D.

           •   The needs of all entities using poison center services, including corporations,
               emergency medical services, state universities, and state and federal agencies.
               Details in Appendix E.

           •   Staffing needs for the network, including the number of, need for, and availability
               of qualified staff. Details in Appendix F

           •   Other analyses of the structure and functions of poison centers, both in Texas
               and throughout the country. Details in Appendix G


        TEXAS POISON CONTROL IN ACTION

        The TPCN is a 16-year proven program for the State of Texas that provides significant
        returns of $7 on the investment of every $1 spent. These returns take the form of
        significant healthcare cost savings; affordable and accessible healthcare; public health
        that is second only to childhood immunizations in cost-effectiveness; health professional
        clinical training and education; public poison prevention; emergency preparedness and
        response; and real-time toxicological and surveillance in recognizing public health
        threats.




CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                3
        The TPCN received over 414,194 calls in fiscal year 2010. The following is one
        example of the health care services provided by Poison Control Centers every day.

               A certified specialist in poison information, or C-SPI, received a call from
               the mother of a 13-year-old child who had ingested 65 diphendyramine
               (Benadryl ®) pills. The child was nauseated and becoming sleepy. The
               C-SPI referred the child into the emergency room; as the mother was
               pulling into the parking lot she hung up on the C-SPI. The C-SPI
               attempted to call the mother six times without answer, wanting to share
               treatment recommendations with the healthcare staff at the emergency
               room. The C-SPI had obtained the caller’s zip code and, knowing the
               area, began calling local emergency rooms to locate the patient; five were
               contacted before finding the patient. Based on the child’s symptoms and
               clinical presentation, the C-SPI recommended benzodiazepine treatment
               without more expensive decontamination procedures. The patient was
               transferred to a tertiary hospital capable of handling more complex cases,
               and the recommendations of the C-SPI were passed on. The physician at
               the hospital was concerned that the patient needed decontamination, but
               after contacting the TPCN and speaking with the toxicology Medical
               Doctor on call who verified the original recommendations of the C-SPI, the
               patient was treated without decontamination or other complications and
               was transferred to a psychiatric facility 4 days after the initial ingestion and
               call.

        The TPCN has an important and integral role in supporting the state’s emergency
        preparedness and response needs by implementing requirements of the Public Health
        Emergency Preparedness (PHEP) grants as it relates to real-time disease detection and
        the ability to manage sudden, unexpected increases in call volume in the event of
        chemical, biological, radiological, or nuclear threat or exposure. In addition each SPI is
        fully HAZMAT trained and provides a local on-site “surge” capacity in the event of a
        local disaster, with poison call services maintained through the other 5 Centers. These
        services are provided in partnership with the Department of State Health Services and
        are funded in part by the PHEP grants from the Centers for Disease Control (CDC).

        The TPCN serves a critical need in educating health care professionals in partnership
        with the state’s institutions of higher education. Each Center trains students not only
        from their Host Institution, but also through cooperative agreements with other higher
        education institutions in providing required training for specialized health care fields
        such as medical, pharmacy and nursing. The TPCN serves the needs of over 40
        institutions of higher education, including the University of Texas, Texas A&M
        University, Texas Tech University, West Texas A&M, Baylor College of Medicine, Texas
        Southern University, the University of Houston, the University of North Texas, and many
        more. See Appendix E for a complete listing. The TPCN also provides training for
        Brooke Army Medical Center, Darnall Army Hospital, and the William Beaumont Army
        Medical Center.

CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                  4
        The regional Centers’ knowledge of local health care systems serves the diversity of
        Texas. Each Center has intimate knowledge of local risks and resources that are
        critical in emergency call management. Potential poison exposures, and therefore calls
        to the TPCN, vary across the state, and include agricultural, industrial, and
        environmental risks. Delivery of emergency health care relies on intimate knowledge of
        local resources, local barriers to access, and rapid immediate response to the specifics
        of the caller’s situation. Each Center maintains information on local hospitals’ and
        emergency departments’ capabilities, the availability of antidotes, and has the capability
        to support callers speaking Spanish, English or both. See Appendix D.


        CURRENT STATUS
        Statutory Framework
        The Texas Poison Control Network (TPCN) was established by the 73rdLegislature in
        1993 in Health and Safety Code (HSC) Chapter 777; subsequently amended, most
        recently by House Bill (HB) 1093 during the 81st Legislative session in 2009. The major
        program change made by HB 1093 was to move total management of the TPCN to the
        CSEC from a shared management model with the Department of State Health Services
        (DSHS); this transition was completed in May 2010.

        As established in Health and Safety Code, Chapter 777 (HSC 777), the TCPN consists
        of 6 Regional Poison Control Centers (Centers) located within a host Health Science
        Center or a Hospital District (Host Institution) within the State. The potential to add a
        seventh center exists in statute. The six regional Centers designated in statute as the
        regional poison control centers for the state are provided in the chart below. The
        regions covered by each Center are illustrated by the map following this section.




CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                5
                                REGIONAL POISON CONTROL CENTERS

          Texas Panhandle Poison Center                   Texas Tech University Health Sciences
                                                          Center at Amarillo
          North Texas Poison Center                       Dallas County Hospital District
                                                          (Parkland)
          West Texas Regional Poison Center               University Medical Center of El Paso, El
                                                          Paso County Hospital District
          South East Texas Poison Center                  The University of Texas Medical Branch
                                                          at Galveston
          South Texas Poison Center                       The University of Texas Health
                                                          Sciences Center at San Antonio
          Central Texas Poison Center                     Scott and White Memorial Hospital,
                                                          Temple


        Through the use of dedicated funds generated through a long distance surcharge, the 6
        Centers receive grants from CSEC to operate statewide toll-free emergency
        consultation, referral, and treatment 24 hours a day, 365 days a year (24/7/365) to
        manage resident and health professional concerns regarding toxic exposures, possible
        acute poison exposure, and expert toxicology consultation. The Poison Control
        Program is dependent on the revenues generated from the equalization surcharge. The
        surcharge is imposed as a percentage of intrastate long-distance charges.
        HSC 777 defines the services the Centers must perform, which are: 24 hour toll free
        telephone referral and information service for the public and health care professionals;
        maintain connectivity to the 9-1-1 public safety answering points; provide assurance that
        the activities meet the criteria established for certification by the American Association
        of Poison Control Centers (AAPCC); provide community education programs; provide
        informational packets on poison prevention to parents of newborns; provide information
        and education to health professionals; provide professional and technical assistance to
        state agencies; and provide consultation services concerning medical toxicology. It is
        desirable that the Centers conduct research programs to improve treatments for
        poisoning victims. In coordination with DSHS, the Centers must maximize the use of
        data collected through the network to assist in quality control, research, and
        coordination with other public health activities.




CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
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CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                7
        Current Structure
        The TPCN serves the entire state and provides health care services and information to
        people who suspect they have been exposed to poisonous and toxic substances or
        desire information about toxins by dialing a toll-free telephone number, 1-800-222-1222.
        The network is composed of six regional poison control centers residing in host
        hospitals, linked by an advanced telecommunications managed services network. Each
        9-1-1 Public Safety Answering Point has direct telephone access to at least one poison
        control center and can be rerouted as necessary.
        The basis of the TPCN’s organization and funding is the CSEC strategic plan and
        legislative appropriation. The goal is to maintain high quality poison control services in
        Texas, through the operation of the state poison communication system by funding the
        following strategies.

        POISON CALL CENTER OPERATIONS
        CSEC contracts with the six Centers for the operation and maintenance of the state
        poison control call centers. The primary cost of this strategy is SPI and C-SPI salaries.
        Callers speak directly with SPIs and C-SPIs with the aim of providing sufficient
        information to treat a poison incident at home, and avoid the dispatch of emergency
        medical services or a visit to the emergency room. The program serves all of the
        people in Texas, both citizens, visitors, and healthcare facilities with access to
        telephone-based health care services and information. A significant factor affecting
        poison call center operations is the competitive employment environment for call takers.
        SPIs and C-SPIs, who are required to be either pharmacists or registered nurses, are in
        high demand in both the private and public sectors. A significant factor affecting poison
        call center operations is the competitive employment environment for health care
        professionals.

        STATEWIDE POISON NETWORK OPERATIONS
        CSEC utilizes this funding to contract with service providers for the telecommunications
        services necessary to operate and maintain the existing poison control
        telecommunications network, including equipment replacement. Costs met under this
        strategy include: an advanced telecommunications network procured through the
        Department of Information Resources (DIR); call taker equipment and maintenance;
        toxicological databases for call handling; and case management software. A significant
        impact to statewide poison network operations is the ever-changing technological
        environment. The digital network, computers and computer-to-telephony interface
        equipment used in the poison centers require periodic replacement. Transition to a
        managed services business model in FY 2007 supported by the DIR has permitted the
        CSEC to build future replacement costs into the recurring operating costs for the
        network and decrease the peaks and valleys in funding these requirements.




CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                8
        CSEC POISON PROGRAM MANAGEMENT
        This strategy provides for the timely and cost effective coordination and support of the
        entire Texas Poison Control Network.             The CSEC performs poison program
        management by contracting and coordinating with the six Centers for poison center
        operations; and, with the telecommunications network providers, DIR; equipment
        vendors; and toxicological database service providers. The primary costs met by this
        strategy are direct salaries for three FTE positions at CSEC.



        TPCN FUNDING AND PERFORMANCE
        The amounts appropriated to CSEC for the strategies supporting the TPCN, and related
        performance measures for FY 2010 – 11 are reflected in the tables below:


                 Current Appropriation Amounts (Adjusted to reflect required reductions)

                                               FY 2010                    FY 2011
        Poison Call Center                     $6,619,459                 $6,507,373
        Operations
        Statewide Poison Network               $ 998,263                  $1,086,932
        Operations
        CSEC Poison Program                    $ 147,125                  $ 289,130
        Management
        Total                                  $7,764,847                 $7,883,435


                               Poison Program Performance (Target/Actual)

                                                  FY 2010 Target          FY 2010 Actual
        Percentage of Time the                       99.50%                     100%
        TPCN Managed Services
        are Available (Key)
        Total Number of Poison                        412,470                   414,194
        Control Calls Processed
        Statewide (Key)
        Average Cost per Call                          $19.58                    $19.80
        Processed
        Number of Poison Control                          0                         1
        Answering Point (PCAP)
        Outages that Exceed Two
        Hours 




CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                              9
        CURRENT ASSESSMENT
        The TPCN meets its current performance targets within appropriated funding amounts.
        The Center operations component is in transition due to the change of oversight from
        DSHS to CSEC in 2010. This transition presents challenges and opportunities to CSEC
        and the Centers. Since program management was transferred to CSEC in May 2010,
        CSEC staff has begun evaluating TPCN operations. The CSEC’s current assessment
        is that the term “network” applies primarily to the telecommunications infrastructure
        portion of the TPCN; the operational aspects of the program do not function as a true
        network, with each Center functioning in many ways as an independent Center. To
        further enhance and maximize the potential of the TPCN, CSEC will pursue the concept
        of network systemization and Center specialization to minimize duplicative functions
        while building on the unique aspects of each Center.




CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                          10
        ASSUMPTIONS
        In conducting its evaluation of alternative structures for the TPCN, the CSEC made the
        two basic assumptions discussed in this section.
        Assumption 1: Current service level should be maintained.
        This assumption is consistent with CSEC’s mission, which is to preserve and enhance
        public safety and health in Texas through reliable access to emergency
        telecommunications services, including 9-1-1 service, and poison prevention, treatment,
        and education services. The current level of service level is defined as the FY 2010
        performance measure targets, and other critical performance levels not currently
        reflected in the agency’s performance measures, which include: numbers of Human
        Exposure calls, follow-up calls, information calls, education presentations, and health
        professions training. Detail in Appendix D & E.
        Assumption 2: Accreditation from the American Association of Poison Control Centers
        (AAPCC) would be maintained.
        AAPCC accreditation is critical for many reasons including providing quality control,
        standard operating expectations, standardization of personnel capabilities, and
        assurance of quality medical oversight for Center functions. Most germane to the
        question of restructuring, however, may be the fact that certification by AAPCC is vital to
        maintaining the ability of the Centers and the TPCN to receive additional Federal
        funding.    Sources of Federal funding include: Health Resources and Services
        Administration (HRSA), which awards non-supplanting stabilization enhancement,
        public education, disease-related surveillance, and other special project grants; Centers
        for Disease Control and Prevention, which awards the Public Health Emergency
        Preparedness grants through DSHS; and the AAPCC itself, which awards research
        grants that provide support to the salaries and research of SPIs and Educators. Loss of
        accreditation would jeopardize the consideration of Texas Centers for any of these
        grants, most of which are currently received. The factors critical to maintaining
        accreditations are available in Appendix A.




CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
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        EVALUATION OF OPTIONS FOR THE STRUCTURE OF THE TEXAS POISON
        CONTROL NETWORK
        CSEC staff collected data through telephone conversations with other State Directors;
        meetings with each Texas Center and the CEO or their representative of each Center’s
        Host Institution; research of Poison Center accreditation and standards; and extensive
        discussions with each Center Director and the Poison Control Coordinating Committee
        to gain insight into the critical factors in Poison Center functioning. The CSEC selected
        for consideration three options for the structure of the TPCN.
           1. Consolidate the 6 Centers into 1
           2. Consolidate the 6 Centers into 3
           3. Maintain the 6 Center structure with extensive latitude for CSEC to standardize
              the network and bring efficiency to its function


           1.      CONSOLIDATE THE SIX POISON CENTERS INTO ONE
           Consolidation of the TPCN to one location serving the entire State offers the
           advantages of minimizing administrative costs and standardization of operations
           across the state. The recently published Legislative Budget Board Performance
           Review Report on Poison Center Consolidation documents this approach and
           estimates the savings at $2,300,000 for the FY 2012 – 13 biennium, and $1,500,000
           per year thereafter. According to the report, this fiscal impact is based on
           consolidating six regional centers into a single statewide center and eliminating 18
           non-call taker FTE positions; and, accounts for projected overhead costs at the
           consolidated center and allows for potential increased travel expenditures by
           education program staff post-consolidation. The proposed rider is as follows:
                   Contingency for the Consolidation of the Texas Regional
                   Poison Control Centers. Included in the amounts above is
                   $5,479,230 in fiscal year 2012 and $5,367,144 in fiscal year 2013 in
                   General Revenue-Dedicated Commission on State Emergency
                   Communications Account No. 5007 in Strategy B.1.1, Poison Call
                   Center Operations, for poison control center operations which
                   leaves in place the existing number of regional poison control
                   centers at six. Alternatively, and contingent on enactment of Senate
                   Bill/House Bill XX, or similar legislation by the Eighty-second
                   Legislature, Regular Session, 2011, the regional poison control
                   centers are consolidated with no additional fiscal implications. Also
                   contingent on enactment of Senate Bill/House Bill XX, or similar
                   legislation by the Eighty-second Legislature, Regular Session, 2011,
                   the Commission on State Emergency Communications shall submit
                   a plan for consolidating the six regional poison control centers to the
                   Governor and Legislative Budget Board by October 1, 2011.

CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                              12
           While this alternative is technologically feasible, CSEC has identified the following
           concerns which would require additional resources:

               •   AAPCC accreditation requirements could not be met with the single center
                   model. The TPCN is currently staffed appropriately to meet the human
                   exposure calls per SPI requirement. However, the one center model would
                   not meet the requirement that a center should serve a region covering no
                   more than 10 million in population. Based on Texas’ population, there would
                   need to be at least three centers.

               •   No single Poison Center is presently configured to house the number of
                   personnel required to staff a single center model without major modifications.
                   Modifications would be site specific, but could include facility construction or
                   remodeling, electrical, network and backup power costs in an existing center
                   to accommodate the increased staff. The use of satellite centers and/or
                   remote agent call takers would mitigate this issue; however, additional
                   resources would be required to establish a new telecommunications network
                   configuration to support these alternatives. The TPCN currently includes nine
                   (9) remote agents, who are funded through federal Public Health Emergency
                   Preparedness grants through the DSHS and not CSEC appropriations.

               •   There are insufficient numbers of qualified SPIs and Medical Toxicologists
                   physically located in any one area of the State to meet the needs of a single
                   center capable of supporting the current level of service. Additional resources
                   would be required to recruit and relocate the necessary additional staff, and to
                   establish a new telecommunications network configuration to support remote
                   agents or satellite centers. The number of remote agents required is
                   estimated to be 30, which would require $646,350 in the first year, and
                   $786,600 in subsequent years. See Appendix C.

               •   Medical oversight to maintain accreditation requires at least 3.6 MDs at the
                   current human exposure call levels. Medical oversight of SPIs working from
                   remote sites or satellite locations would necessitate additional costs for time
                   and travel. If local medical oversight is not available, increased travel will be
                   incurred for the supervising Medical Toxicologist(s) to visit the site and
                   monitor SPI performance, provide ongoing training, and assure quality health
                   service delivery. Public education is currently provided by the Centers and is
                   required for AAPCC certification. This involves a variety of activities including
                   but not limited to information dissemination through written text as well as
                   presentations, train-the-trainer activities, health fairs, and school
                   presentations. Under this scenario, additional resources would also be
                   required to meet the regional public education requirements of the AAPCC.

               •   Loss of host institution in-kind support. It is anticipated that, were any host
                   institution asked to take on a broader role due to consolidation, it would begin
                   charging indirect costs. This could add significant costs to the State. Only 1%
                   of allowable indirect costs are currently reimbursed to host institutions through

CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                 13
                    state funds, the additional indirect costs for a single center model could total
                    approximately $1,350,000 per year. See Appendix B.

                •   A single center model introduces a single point of failure and is a significant
                    risk. While remote agents could offer some backup, they cannot function
                    alone as they rely on connectivity to the TPCN through a Center. This risk
                    could be mitigated, but there would be additional costs associated with
                    establishing a secondary backup in Texas or in another state. Other states
                    also have limited capacity and may not be able to answer all of Texas’ calls
                    should a network failure occur.

                •   Significant change in the TPCN structure over a short time period could result
                    in interruptions to operations and cause loss of service. The LBB report
                    recommends a six-month transition for consolidation from six to one center.
                    The State of California required years to transition to its current consolidated,
                    four site system. See Appendix G.
           2.       CONSOLIDATE THE SIX POISON CENTERS TO THREE
          Consolidation of the Network into three locations serving the entire state also offers
          an opportunity for reducing administrative costs. Because the TPCN is currently
          staffed at the minimum required level of 53.3 FTE SPI positions, this option would not
          result in savings of those salaries. It would result in some savings by reducing the
          number of Managing Directors, Educators and Administrative FTE positions and
          other operating expenses. However, costs related to salaries for the remaining
          management and administrative FTE positions may increase somewhat due to an
          increase in responsibilities and the size of the region to be managed. Other
          advantages of this recommendation are that it maintains the Centers’ ability to meet
          the AAPCC certification requirements, and maintains some regional capacity as
          required for certification. It also maintains some capacity for health professional
          training, and provides an amount of redundancy in the TPCN in the event of disaster,
          terrorism, or single Center system failure.
          While this alternative is also technologically feasible, CSEC has identified the
          following concerns that would require additional resources:

                •   Reconfiguration of the remaining three Centers may be necessary to house
                    the number of personnel required to operate. Modifications would be site
                    specific, but could include facility construction or remodeling, electrical,
                    network and backup power costs in an existing center to accommodate the
                    increased in-center staff.

                •   There may not be sufficient numbers of necessary qualified SPIs and Medical
                    Toxicologists physically located in the vicinity of the three remaining centers
                    to meet increased capacity requirements. Additional resources would be
                    required to recruit and relocate the necessary additional staff and to establish
                    a new telecommunications network configuration to support remote agents or

CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                  14
                    satellite centers. The number of remote agents required for this option is
                    estimated to be 22; first year costs would be $473,990, with subsequent
                    annual costs of $576,840. See Appendix C.

                •   Medical oversight of SPIs working from remote or satellite sites would
                    necessitate additional costs for travel.

                •   Public education activities to maintain AAPCC certification require travel.
                    Regional public education programs entail less cost for travel relative to a
                    centralized model associated with consolidation. Under this scenario,
                    additional resources would be required, although not to the extent of a one-
                    center model.

                •   Loss of host institution in-kind support. It is anticipated that, were any host
                    institution asked to take on a broader role for their center due to
                    consolidations, they would begin charging indirect costs, which could add
                    significant costs to the State. This option would also include the complete
                    loss of the contributions of Medical Toxicology support from three Host
                    Institutions. See Appendix B.
           3.       MAINTAIN THE CURRENT SIX-CENTER STRUCTURE WITH EXTENSIVE
                    LATITUDE FOR CSEC TO STANDARDIZE THE NETWORK AND BRING
                    EFFICIENCY TO ITS FUNCTION.
          This option could continue operation of the current six poison centers at the funding
          level contained in Rider 8 of CSEC’s appropriation in the introduced versions of
          House and Senate General Appropriations Act for FY 2012 – 2013, and could
          represent savings of approximately $2.3 million for the biennium. This is the same
          level of funding as would be provided if consolidation occurred. This alternative is
          viable given that there are management tools and mechanisms available to enhance
          the efficiency of the current system. No additional resources would be associated
          with this option.
          While this option would eliminate the costs of reconfiguration of poison centers
          and the supporting telecommunications network, CSEC has identified the following
          concerns that would need to be addressed through increased standardization and
          controls:

           •    Not all poison center services that are provided today could be provided at the
                proposed funding level. The goal of the six poison centers is to provide the best
                possible service as outlined in the enabling legislation. This service begins with
                the quality of care of a poisoned patient and extends to providing community and
                professional education. Pill identification calls that are not related to human
                exposures would need to be eliminated. In FY2010, the network handled 92,884
                pill identification calls. Of those, 16,801 were from law enforcement; another
                significant source of these request is school nurses. Changes would also be
                required to the current models for handling information calls and managing low
                acuity patients, by using lower paid students, pharmacy technicians and
CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                15
               paramedics instead of SPIs. Other changes required would include freezing staff
               salary levels, eliminating reimbursement of all indirect costs to host institutions,
               limiting reimbursement of personnel fringe benefit costs to host institutions,
               network certification and network wide scheduling of SPIs. These changes
               would require Commission action. See Appendix H.

           •   Reconfiguration of the physical locations of the Centers would not be necessary.
               However, CSEC would pursue the concept of network systemization and Center
               specialization to minimize duplicative functions while building on the unique
               aspects of each Center. Since the program management was transferred to
               CSEC in May of 2010, CSEC staff has begun to evaluate TPCN operations. The
               CSEC’s current assessment is that the term “network” applies primarily to the
               telecommunications infrastructure portion of the TPCN; the operational aspects
               of the program do not function as a network, with each Center functioning in
               many ways as an independent Center. For instance, almost all functions are
               replicated in each Center; few standard operating procedures exist; staffing
               patterns are not standardized; performance expectations are not well articulated
               and enforced; grants are not awarded on a competitive basis; and reporting has
               been inconsistent. System certification by the AAPCC would be required to
               implement network-wide staffing and scheduling, and should result in reduction
               of FTEs and personnel costs.

           •   Qualified staff is in place to support the six Centers; however, maintaining the
               required staffing levels is an on-going challenge due to the competitive health
               care professions job market. System certification of the TPCN by the AAPCC is
               a key opportunity for streamlining and improving the current structure. System
               certification allows for efficiencies such as standardized staffing which allows
               Centers to close at off-peak times; standardized operating procedures; shared
               duties at management and oversight levels; and reductions in other overlapping
               functions such as public and professional education. This would allow staff to be
               utilized more effectively and efficiently with potential downsizing over time
               through attrition in a controlled manner that assures the ongoing provision of vital
               health services. Currently, each Center is individually certified, which puts Texas
               in the position to pursue AAPCC system certification now.

           •   Medical oversight and public education activities required to maintain AAPCC
               certification require travel. Regional public education programs entail less cost
               for travel relative to a centralized model associated with consolidation. Under
               this scenario, no additional resources would be required for travel costs related to
               either public education activities or medical oversight.

           •   Significant change in the TPCN structure over a short time period could result in
               interruptions to operations and cause loss of service. Maintaining the six Center
               model avoids sudden change and potential interruptions in operations and loss of
               service.



CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                16
        RECOMMENDATION
        CSEC recommends maintaining the current six-center structure with extensive latitude
        to standardize the network and bring efficiency to its function. This option builds on the
        strengths of the current system and allows for efficiencies to be found; it continues the
        vital Host Institution contributions; it utilizes regionalization to provide services to reflect
        diversity and to meet local needs; it mitigates network single points of failure and
        possible outages due to natural or manmade disasters; and, it results in savings over
        time.
        In order to implement the CSEC recommendation, the statutory language in HSC 777
        would need to be changed to be permissive as to the locations of the Poison Center
        sites. CSEC would need delegated authority and latitude to implement the required
        management and efficiency controls. CSEC would be required to develop a plan and
        reasonable timeline for implementing the changes.
        The individuals who manage, operate, and staff each Poison Center within TPCN are
        professionals strongly committed to health care service delivery and poison prevention.
        Through this strong commitment and collaboration, the CSEC and the Poison Centers
        will reorganize the TPCN to operate more efficiently and effectively to meet the needs of
        Texas.




CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                     17
                       APPENDICES




CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                18
                                                                                 APPENDIX - A
        AAPCC ACCREDITATION REQUIREMENTS:

           •   Total population: Each Center should serve a region covering no more than 10
               million in population. Based on its current population of 24.8 million (U.S. Census,
               2010), Texas would need at least three Centers to fully serve the State and maintain
               AAPCC accreditation.

           •   Service Availability: Services must be provided 24 hours per day, 7 days per
               week, 365 days per year (24/7/365), with at least 1 SPI or Medical Toxicologist on
               site at all times. See below for staffing implications of this and other requirements.

           •   Medical Director: A full time MD position is required for each 50,000 human
               exposure case calls received. In fiscal 2010, the TPCN received 181,151 human
               exposure calls. This translates to 3.6 full time MD FTEs on a statewide basis. The State
               currently pays for 2.03 MD FTEs. Please see Appendix B regarding “In-Kind”
               contribution of Host Institutions to Medical Oversight regarding the total qualified MD
               hours of support the TPCN receives; these contributions are critical to being able to
               meet the requirement for physician hours, as well as the requirement for on-site
               supervision of SPIs.

           •   SPI requirements: Each SPI should handle an average of 3500 human exposure
               (HE) calls per year. Based on FY 2010 numbers, this translates to 51.75 SPIs
               statewide for Texas. Accounting for staffing and Center management experience in
               covering sick leave, vacation time, staff turnover, training of new SPIs, certification time,
               and other human resource needs, a 15-20% leeway must be added to assure the
               24/7/365 coverage required. Thus, based on FY 2010 demand, the TPCN should staff
               59.51 to 62 SPIs. The TPCN currently staffs 57.8 SPI FTEs, not all of which are filled
               and not all of which are funded through State funds. The AAPCC recognizes that
               “Number of Human Exposure Calls” serves only as an indicator of overall SPI demand; it
               does not reflect the total demand on SPI workload. In fact, the number of “Information
               only” calls in Texas has risen dramatically in the past several years, from 68,200 in 2000
               to 183,534 in 2009. ”Information Only” calls often require a more intense time-
               commitment from the SPI due to the complexity of the call; therefore, basing staffing on
               meeting only the Human Exposure call requirement should be considered a minimum
               staffing level.

           •   Staffing: 50% of SPIs employed at an accredited center must be AAPCC Certified.
               Certification requirements are rigorous and impact the ability to relocate staff in the
               instance of Center consolidations. Requirements include:
                   o Possessing an MD, RN, or PharmD license
                   o Initial certification exam: A SPI may not sit for the exam until they have logged in
                       at least 2000 hours of call-taking. Even with this level of experience and a
                       preparatory training course, it is not unusual for a SPI to require 2-3 examination
                       periods to successfully pass and obtain certification.           Passage on first
                       examination is unusual on a nationwide level; according to the 2009 CSPI
                       National Data provided by AAPCC success rate for SPIs seeking certification
                       exam was 46.7%, which includes non-certified individuals sitting for the exam a
                       second or third time.
CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                         19
                   o   On-going Continuing Education of 20 hours per 2 year period for RNs, 30 hours
                       per 2 years for PharmDs, and 24 hours per 2 years for MDs.
                   o   Recertification testing every 7 years: Recertification generally involves taking a
                       2-day training course, which is currently offered only in New York or in El Paso,
                       and then sitting for the exam. Estimated minimal costs include: $250 exam cost;
                       $248 average course cost; $900 average travel cost to course city including
                       hotel; and $105 average per diem, for an average total of $1503 per SPI per 7
                       years. Most Centers assume these costs since they are required to have 50% of
                       SPIs certified to meet AAPCC accreditation.

           •   Managing Director: A managing director must be an RN, PharmD, or MD. If the
               Medical Director serves as the Managing Director, he/she must be full time. This
               requirement places constraints on hiring and pay-grade for Management which must be
               considered in any structural changes to the TPCN. When full time physician coverage is
               not available, the Managing Director must be a diplomat of the American Board of
               Toxicology or board prepared. It should be noted that an ABAT certified/prepared
               person is more difficult to find than physician toxicologists or C-SPIs.


           •   Regionality: Each Center must have an awareness and knowledge of the Regional
               Health Care Facilities, their capabilities, their toxicology laboratory capabilities,
               patient transportation services, and antidote availability. This requirement poses a
               unique challenge to Texas. With our broad regional differences, unique regional
               characteristics, and variation in regional capabilities, it is very difficult to conceive of
               providing specialized regional knowledge from fewer than six Centers. In the often life-
               threatening cases managed through the Centers, every second makes a difference. Not
               knowing the nearest available ER, or not knowing the location of the nearest available
               snake-venom antidote, can mean critical lost minutes in referring patients and saving
               lives. The AAPCC recognizes these constraints in this requirement and therefore
               demands the regional familiarity necessary to swiftly and specifically answer calls.




CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                        20
                                                                               APPENDIX - B
        HOST INSTITUTION SUPPORT
        The State of Texas benefits from the services that each Center provides in collaboration with its
        Host Institution. In preparation for this report, CSEC obtained input both in person and in writing
        from the Chief Executive Officer (CEO) or their designate at each Host Institution; letters of
        support for their respective Centers were submitted by each Host Institution and are included in
        Attachment I to this report. It is apparent that each Host greatly values their affiliated Center,
        and for that reason, they provide extensive In-Kind contributions to their Centers, as outlined in
        the table below. An example of Host Institution In-Kind support is also provided.

                            In-Kind Host Institution Contributions (FY 2010)

                              Allowable           Indirect as
                                                                    Monthly M.D.         Monthly M.D.
                            Indirect Costs        Percentage
     Poison Center                                                   Hours Paid         Hours Actually
                                  Not               of State
                                                                     by CSEC**           Provided***
                             Reimbursed*            Grants

         Texas
                               $211,610               26%                 80                   160
       Panhandle

      North Texas
                               $183,231               14%                 80                   645
     Poison Center

      West Texas
       Regional                $221,297               24%                  0                   112
     Poison Center

       South East
      Texas Poison             $583,564               42%                 72                   240
         Center

      South Texas
     Poison Center             $412,126               37%                 58                   400
     (San Antonio)

     Central Texas
     Poison Center             $166,983               17%                 69                   564
       (Temple)

           Total              $1,778,811              27%                359                  2,121




CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                        21
           * Calculated using FY 2010 grant amounts and host specific indirect rates.

           ** Calculated using a 40-hour workweek and percentage of MD FTE paid with State funds.

           *** These figures do not include over 700 hours per month for each center having the
           required MD Toxicologist on call and available at all times.

        Because of the value each Center contributes, and because of the unique service each center
        provides to its region, the Hosts have not historically charged the grant program for their usual
        allowable indirect costs. An example of this added value is that, without the North Texas Poison
        Center, Parkland Hospital and UT Southwestern Medical School could likely not maintain their
        Medical Toxicology Fellowship training program. This would be a tremendous loss to the State
        of Texas, as certified Medical Toxicologists are in short supply nationally and in Texas and are
        the only specialists who can assure rapid and proper management of a broad variety of human
        poisonings, venom exposure, and other toxic exposures. Furthermore, because of the
        necessity for a critical number of Medical Toxicologists to support an effective Texas health care
        infrastructure by providing publically available consultation and training for health care facilities
        across the State, each Host Institution provides many more Toxicology physician hours than
        those paid through the CSEC grants. It is highly likely that, were any Host Institution asked to
        take on a broader role for their Center due to consolidations, they would begin charging indirect
        costs, which could add significant costs to the State. In fact, in personal communications with
        Host CEOs, several expressed a willingness to expand their programs, with appropriate if not
        exactly commensurate funding increases, but indicated that assuming responsibility for a larger
        portion of the State would in fact result in the initiation of indirect charges due to an inability to
        justify their own Institution assuming these costs for regions outside of their direct medical
        service responsibility.

        As noted above, Texas healthcare facilities rely heavily on Medical Toxicology consultation and
        input from Center experts. One Center toxicologist estimates that he receives 50% of his calls
        between 5 pm and 8 am including weekends, with one or more calls occurring between 2 am
        and 5 am 4-7 days per week. This level of consultation, along with the duties of SPI oversight
        and teaching required by the AAPCC, is one reason that the AAPCC sets standards for the
        number of Toxicologist/Medical Directors required, based on Human Exposure calls.

        ESTIMATED ADDITIONAL INDIRECT COSTS

        Based on the above information, CSEC assumes that centers remaining in either the 1 Center
        or 3 Center option would begin charging indirect costs. No additional indirect costs re assumed
        for the 6 Center model since the current responsibilities for each Center would remain
        essentially the same, if not be reduced.

                                                  FY2012             FY2013                BIENNIUM
        Proposed Funding                         $5,479,230         $4,367,144            $10,846,374
        Estimated Indirect Rate                     25%                25%
        Estimated Additional Indirect            $1,369,808         $1,341,786             $2,711,594
        Costs




CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                           22
                                                                                    APPENDIX - C
        MODELS OF CONSOLIDATION COSTS AND CONSIDERATIONS FOR STAFFING
        AND WORK STATION REQUIREMENTS
        Staffing: Role of Remote Specialists in Poison Information (SPIs) in a poison control
        setting

        In preparation for this report, CSEC sought and received information from three other States
        (Illinois, Missouri, and Colorado) that have experience in using remote (off-site) SPIs in their
        Poison programs. The assumption in developing a remote capacity is that it serves as a vital
        resource for surge capacity during natural disasters, times of media attention to handle
        increased call demand, inclement weather situations that may impair access to a Center, and
        during public health threats; it is also a useful staffing tool for “just in time” coverage that allows
        some options for management in staffing flexibility.

        It should be stressed that the SPIs are delivering health care under the licensure of the
        managing Medical Director; therefore, a level of direct intermittent supervision is required to
        assure quality delivery of care and to maintain the appropriate level of health expertise and
        maintain training to stay current with changing health standards. For this reason, “long
        distance” telecommuting is not an option that allows a Medical Director to gain the level of
        confidence in allowing SPIs to function under his/her medical license.
        Consistent conclusions from the three States consulted include:

            •   Instant access to an in house supervisor and toxicology consulting staff is necessary.
            •   Remote agents must spend time on a regular basis (usually weekly) in the Center for
                the purposes of training, socialization, peer consultation, and quality control.
            •   Remote agents must be readily available to travel into the Center within a short (30
                minute-1 hour) period of time to cover staffing emergencies, and to continue their
                scheduled shift in the event their remote technology goes down.
            •   Because the Remote agent works in two locations, duplication of equipment and higher
                technical support costs are incurred.
            •   Many remote agents work 0-2 shifts per week from home; this has implications for
                creating and paying for 24-hour hard line connections versus using VoIP and internet
                connections.
            •   Internet connectivity and onsite technical failures are not uncommon; quality issues with
                VoIP have been experienced.

            In summary, the data provided by the three states reveal that the option of using Remote
            agents has its advantages for providing surge capacity, and is a capability that should be
            available to Poison programs. However, on a per FTE basis remote agents are clearly
            more expensive than having staff in-house centrally due to IT needs and frequent travel
            required to maintain the oversight and quality health care delivery required of the Poison
            program staff.


CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                            23
        Remote Agent Workstations - Equipment and Network requirements to support poison
        control SPIs.

        To work remotely, or off-site, the SPIs must have the same equipment, software, databases and
        connectivity to the telecommunications services that support the TPCN. The costs provided are
        based on estimated pricing from the CSEC’s current service providers, and are presented for
        the 1-center and the 3-center options discussed in the report.

        There are currently a total 43 workstation positions located in the six Centers which are used by
        the SPIs to answer and handle calls to poison control. They are distributed as follows:

                                 Workstation Positions by Center - Current
          Poison Center                                               Number of Workstation Positions

          Texas Panhandle Poison Center - Amarillo                                  5
          North Texas Poison Center - Dallas                                       10
          West Texas Regional Poison Center - El Paso                              5
          South East Texas Poison Center - Galveston                               10
          South Texas Poison Center - San Antonio                                   7
          Central Texas Poison Center - Temple                                     6
                              Total TPCN Workstations (Current)                    43


        To develop remote agent workstation cost estimates, the CSEC made the following
        assumptions:

        Consolidation to 1 Center

        30 remote workstations would be needed to support a one-center model. To develop this
        estimate, CSEC assumed that the TPCN would need to maintain the current number of total
        workstations (43). If the largest center doubled capacity from 10 to 20 workstations, 23 remote
        workstations would be needed to maintain current number of workstations. Additionally, 7
        remotes workstations would be necessary to accommodate variable staffing factors such as
        overlapping work schedules, vacation and sick leave.

        Consolidation to 3 Centers

        22 remote workstations would be needed to support a three-center model. CSEC assumed that
        the TPCN would need to maintain the current number of total workstations (43). If three of the
        existing centers remained, the number of remaining in-center workstations would be 21;
        therefore, 22 remote workstations would be needed to maintain current number of workstations.
        This estimate assumes that variable staffing factors such as overlapping work schedules,
        vacation and sick leave, would be accommodated by the positions remaining at the three
        centers.




CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                        24
        Costs for FY 2012 – 2013 for each of these scenarios are estimated in the following tables:
                             REMOTE WORKSTATION COST ESTIMATES: 1 CENTER OPTION

                  Equipment          Estimated       1 Center         First      Subsequent
                      &              Unit Costs         30            Year         Years
                   Circuits                          Remotes        (6 mos)
              Non Recurring          $8,435        $253,050         $253,050     $0
              (1x setup)
              Monthly Recurring      $2,185        $ 65,550         $393,300   $786,600
              Annual Costs                                          $646,350   $786,600
                         Additional Costs FY 2012-13                      $1,432,950


                             REMOTE WORKSTATION COST ESTIMATES: 3 CENTER OPTION

                  Equipment          Estimated       1 Center         First      Subsequent
                      &              Unit Costs         22            Year         Years
                   Circuits                          Remotes        (6 mos)
              Non Recurring          $8,435        $185,570         $185,570     $0
              (1x setup)
              Monthly Recurring      $2,185        $ 48,070         $288,420   $576,840
              Annual Costs                                          $473,990   $576,840
                         Additional Costs FY 2012-13                      $1,050,830




CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                      25
                                                                                                 APPENDIX - D
         REGIONALITY

         The tables below include FY 2010 data regarding the scope of responsibility and activities. The
         activities listed do not capture the full array of activities performed by each Center, which
         include but are not limited to: data evaluation, quality control, real time data monitoring and
         data reporting to the National Poison Data system; public education; health professional
         education; medical consultation and ongoing professional training to maintain certification.

                                                                                               # of Registered
                                                          Network         Calls Handled
      Poison          % of TX           % of TX                                              Healthcare Facilities       CSEC Grant
                                                           Calls          (Incl. Follow-
      Center         Population        Landmass                                                   in Region              Award (2010)
                                                          Received             Up)


      Texas
                          7%               25%               7%                 8%                     86                   $813,885
    Panhandle

   North Texas           32%               12%              22%                 23%                    120                 $1,267,390

   West Texas             5%               23%               9%                 14%                    49                   $939,973
   South East
                         26%               10%              25%                 21%                    126                 $1,389,439
     Texas

   South Texas           19%               21%              20%                 18%                    90                  $1,113,885

      Central
                         12%               10%              17%                 16%                    60                   $982,251
      Texas
      Total *           100%              100%              100%              100%                     531                 $6,506,823

                                                        # of HE 
       Poison         # of Human Exposure              Follow‐Up          # of Information               #of Professional 
       Center          (HE) Calls Received                Calls            Calls Received           Presentations (# Reached) 
       Texas                 14,487                     16,643                  8,540                        34 (868) 
     Panhandle 
    North Texas                50,081                    41,770                 19,757                       99 (1,572) 
    West Texas                 18,715                    36,387                 10,587                       71 (2,152) 
     South East                41,015                    22,695                 42,045                       44 (1,700) 
       Texas 
    South Texas                28,605                    25,597                 36,880                        37 (617) 
   Central Texas               27,888                    25,816                 28,024                        9 (1,610) 
        Total                  181,151                  169,268                145,833                       285 (8,519) 

   These data are provided with the caution that one cannot evaluate each Center solely based on “call-taking” since they are each health
   care delivery entities.

   A human exposure is when a caller has actual or suspected contact with a substance that can be ingested, inhaled, absorbed or
   applied. The essential aim of the poison center is to triage callers to the appropriate level of health care. The human exposure follow-
   up calls will vary depending on the call treatment protocols for the exposure.

   Information calls include a broad variety of issues concerning toxicology, environmental, public health crisis, food contamination,
   recalls, regional ad pandemic outbreaks or other local events. Request for poison education materials and presentations are also
   information calls.

CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                                              26
        Texas is a large and diverse State, and meeting the AAPCC requirement for regional knowledge
        and representation is a challenge. The current system fulfills this requirement with specific local
        knowledge critical for emergency call management. Whereas the telephonic capacity of the
        current TPCN system could support consolidation, the medical capacity to respond quickly and
        efficiently to a poison-exposure call, where health and life are in the balance, is not so easily
        consolidated. Delivery of emergency health care relies on intimate knowledge of local
        resources, local barriers to access, and rapid immediate response to the specifics of the caller’s
        situation. For instance, one local hospital began refusing pediatric cases on a temporary basis
        due to its needs; the regional Poison Center learned that and was able to respond accordingly
        by referring pediatric cases to other ERs in the interim. This type of local health care facility
        day-to-day status change cannot be captured in a statewide database on a real-time basis
        without extensive data support capability. However, regional facilities can and do manage these
        types of data based on their intimate interactions with their local health care system. Other
        aspects critical to maintaining regional entities in Texas include:

        •   Knowledge of local hospital referral patterns, laboratory capabilities, and age/acuity
            limitations: when a rural patient needed referral for ethylene glycol poisoning (antifreeze),
            the regional Poison Center knew to bypass the nearest hospital because it did not have the
            acute care and laboratory capabilities necessary to manage the medical case. Precious
            minutes were saved in transport.

        •   Exposures, and therefore types of calls, vary across the State. Specific examples include:

            o   Agricultural: San Antonio and Amarillo tend to receive many more calls related to
                agricultural toxicities and chemical exposures, which are quite distinct from household
                toxicity exposures and require a special expertise that is developed over time from
                handling such calls.
            o   Industrial: Dallas continues to receive consultation requests from RSR in Dallas where
                lead poisoning continues to be a concern; the Houston coastline is the world’s leading
                toxic waste site due to the petrochemical industry, and Galveston Poison Control
                toxicologists have developed a unique expertise consulting on such exposures over a
                number of years.
            o   Environmental: El Paso and West Texas residents are exposed to snake bites and
                other arthropod (spider) venom exposures not to mention centipedes and other pests. In
                addition, the reaction and beliefs of the Hispanic culture to such exposures poses unique
                challenges to education and medical management. El Paso and San Antonio also are
                best equipped and most experienced in managing specific toxicities due to ingestion of
                Mexican candies (lead poisoning) and other ethnically-specific exposures such as food
                additives, herbal usage, and asiago (cheese) consumption. Another example of a
                toxicity frequently encountered, mushroom ingestion, also varies by region depending on
                the species of mushroom found.
            o   Response to local needs: The Director of the Southeast Texas Poison Center is an
                active member of the Greater Harris County Emergency Preparedness Committee and
                is currently working to facilitate improved communication between the industries,
                emergency responders and the poison center regarding the nature of and response to
                chemical emergencies. This will in turn produce a more timely and effective notification
                and communication of pertinent information to the public in the event of such incidents.
                Every Poison Center likewise is working in its community to enhance emergency
                preparedness and response.


CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                        27
           o   Weather related: Finally, Texas experiences the full scope of weather emergencies,
               from flooding and hurricanes in Galveston, to dust storms and freezing in Amarillo, to
               Tornados in Dallas, and draught in El Paso and Central Texas. Management of
               weather-related emergencies requires local knowledge and expertise and cannot be
               performed through a centralized entity that has no first-hand knowledge of the local
               affected resources and entities. In addition, the redundancy of multiple centers provides
               critical “fall-back” capacity in the case of any single center being off-line due to weather
               or technical related conditions.

        Maintenance of regional training capability: Having the ability to train medical students, nurses,
        pharmacists and medical fellows in a variety of locations across the State is analogous to
        providing multiple venues for medical student or EMS training; it is not feasible that one
        centralized EMS training school would meet the varied needs of all of the local entities across
        the state. Likewise, differently trained and differently experienced toxicologists are needed to
        fully serve the State’s needs for this specialty; imagine needing a cardiologist to manage a heart
        condition, and only those trained in New York city are available to you. This is clearly not the
        type of health care infrastructure one would accept.

        Finally, the model of the Rocky Mountain Regional Poison Center has been invoked as one that
        serves an entire state as well as other neighboring states. One of the Medical Toxicologists
        currently working within the TPCN has intimate knowledge of this system, having trained there.
        His assessment is that, while the system certainly “works,” the quality of care suffers from a lack
        of local knowledge. Calls into the Poison Network from Montana, for example, result in a SPI or
        Toxicologist being able to provide appropriate front-line information and management but
        unable to provide specific local health-care referral information despite the best efforts to
        maintain data-bases that include such information. Texas would be at risk of losing the high
        quality medical response capabilities we currently possess were significant consolidation to
        occur and result in loss of regional knowledge.




CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                        28
                                                                                  APPENDIX - E
        NEEDS OF ENTITIES USING POISON CENTER SERVICES
        Each Center provides vital functions for the State and its health care infrastructure, including but
        not limited to free physician consultation, health professional education, public education, and
        research. Examples of unique aspects of each Center within the TPCN include the following:

           •   Texas Panhandle Poison Center (Amarillo): Integral to the Texas Tech University
               School of Pharmacy to serve as a site for pharmacist as well as nurse and medical
               student training.
           •   North Texas Poison Center (Dallas): Houses the University of Texas Southwestern
               Medical School Program in Medical Toxicology, a Fellowship program that provides
               extensive training to Medical Fellows and over 100 medical residents, pharmacy and
               medical students per year.
           •   West Texas Regional Poison Center (El Paso): First and only 24/365 bilingual regional
               center certified by the AAPCC; and, houses the Texas Tech University Paul L. Foster
               School of Medicine Medical Toxicology Fellowship that provides sub-specialty training to
               medical toxicology fellows, medical residents, pharmacy and medical students..
           •   Southeast Texas Poison Center (Galveston): Provides critical emergency preparedness
               and response partnership for the largest petrochemical manufacturing region in the
               world, and is a required site for rotations in Pediatric Emergency Medicine Fellows,
               medical and pharmacy students at the University of Texas Medical Branch (UTMB) –
               Galveston.
           •   South Texas Poison Center (San Antonio): Partners with the military (Brooke Army
               Medical Center) to provide training; conducts extensive research on eliminating health
               disparities and increasing Poison Center utilization.
           •   Central Texas Poison Center (Temple): Provides centralized database of patient
               medical cases which supports all 6 Centers, and partners with the Military (Ft. Hood and
               others) to provide education, research, and clinical service.

        Health Professional Training and Education

        An important function of the TPCN for the State of Texas is the health professional training
        provided across the state. The chart below summarizes the types and numbers of students
        trained through the system in FY 2010 alone. Provision of adequate health care training
        opportunities continues to be a challenge across the state and vital training sites would be lost
        with consolidation. Each Center trains students not only from their Host Institution, but also,
        through cooperative agreements, with other Higher Education institutions in order to provide
        required training for many specialty fields. As an example, the Texas Children’s Hospital/Baylor
        Pediatric Emergency Medicine Fellows are required to spend training time in a Poison Center to
        complete their Fellowship and become Board certified. Consolidation of Centers with
        subsequent loss of training space and locations would severely impact, if not eliminate, much of
        this professional training due simply to space constraints. A comprehensive list of the
        Institutions served by the TPCN is provided.




CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                         29
                        Health Profession Students Trained by TPCN (FY 2010)




CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                               30
    INSTITUTIONS AND TRAINING FACILITIES
       TEXAS PANHANDLE POISON CENTER – AMARILLO            NORTH TEXAS POISON CENTER – DALLAS
       Texas Tech University                               Parkland Memorial Hospital
       Health Sciences Center                              University of Texas Southwestern Medical Center
       Campuses in Amarillo, Lubbock, Abilene and Dallas   (Medical Students, Residents and Fellows)

       Clarendon College (Nursing)                         Children’s Medical Center (Emergency Medicine
                                                           Residents and Fellows)
       Amarillo College (Nursing)
                                                           John Peter Smith (Emergency Medicine
       West Texas A&M University (Nursing)                 Residents)
       SOUTH TEXAS POISON CENTER – SAN ANTONIO             Texas Tech Pharmacy Program (PharmD
                                                           Candidates and Residents)
       UTHSCSA (Medical and Emergency medical
       students)                                           UT Pharmacy Program (PharmD Candidates)
       University of Texas, Austin school of Pharmacy      Baylor University, Dallas (Nephrology Fellowship
                                                           Pharmacy)
       Wilford Hall Medical Center (Pharmacy)
                                                           UT Health Science Center, Tyler (Occupational
       UTHSCSA, Regional Academic Health Center            Medicine)
       Harlingen (Medical Students)
                                                           UNT Health Science Center
       Brooke Army Medical Center (Pediatric Residents)
                                                           UTMB (Emergency Medicine Residents)
       University of the Incarnate Work Feik School of
       Pharmacy                                            Darnall Army Medical Center (Emergency
                                                           Medicine Residents)
       SOUTH EAST TEXAS POISON CENTER –
                                                           Oklahoma State University (Emergency Medicine
       GALVESTON                                           Residents)
       UTMB Health                                         TVCC Nursing school (Nursing)
       UTHSC, Houston                                      Navarro Nursing school (Nursing)
       Baylor College of Medicine                          El Centro Nursing School (Nursing)
       Texas Children’s Hospital                           Baylor University Nursing school (Nursing)
       Texas Southern University College of Pharmacy
       University of Houston College of Pharmacy
       University of Texas College of Pharmacy
       University of Houston Clear Lake
       Galveston College
       College of the Mainland
       Houston Community College




CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                        31
  INSTITUTIONS AND TRAINING FACILITIES CONT’D
       WEST TEXAS REGIONAL POISON CENTER – EL               CENTRAL TEXAS POISON CENTER - TEMPLE
                                                            Texas A&M Medical School
       PASO
       University of Houston College of Pharmacy            UTMB (Medical Students)

       University of Texas, Austin, College of Pharmacy     UT HSCSA (Medical Students)

       Texas Tech University College of Pharmacy            Texas Tech HSC (Medical Students)

       University of Texas, El Paso Cooperative Pharmacy    UTHSC, Houston
       Program and School of Nursing                        UT College of Pharmacy, Austin
       University of Texas, Tyler, Southwest Center for     A&M College of Pharmacy
       Pediatric Environmental Health
                                                            University of Florida College of Pharmacy
       Texas Southern University
                                                            University of Mary Hardin Baylor (Nursing)
       Paul L Foster College of Medicine at TTU Health
       Science Center (Emergency Medicine, Toxicology       Temple College (Nursing Paramedics)
       Residents)                                           Central Texas College (Nursing)
       William Beaumont Army Medical Center (Physician      Darnall Amy Medical Center (Emergency
       Assistants, Emergency Medicine Residents)            Medicine, Physician Assistants)
       University of New Mexico (Investigational Studies)   Brooke Army Medical (Emergency Medicine,
       University of Arizona (Investigational Studies)      Physician Assistants)

       Pan American Health Organization of the WHO




CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                         32
                                                                                  APPENDIX – F
        STAFFING
        TPCN is staffed primarily by Registered Nurses (RN), Doctors of Pharmacy (PharmD) and
        Medical Doctors (MD) who are further trained to be Specialists in Poison Information (SPIs),
        who must successfully achieve rigorous accreditation (Certified SPI) by the AAPCC and then be
        re-accredited every 7 years. A Board certified Medical Toxicologist, (MD) serves as Center
        Director and/or Medical Director and assumes responsibility for the quality of medical care
        delivery provided by SPIs. These highly qualified individuals provide consultation to health care
        facilities as well as to the public. In FY 2010 almost 36,000 calls were received through the
        statewide phone number from health care facilities (HCFs) seeking advice and consultation on
        cases; this does not include calls placed by physicians or other health care providers directly to
        local Center staff and Directors. In consultations with the public, from FY 2000 through 2010,
        an average of 171,936 calls regarding possible human exposure to toxins per year were
        received with 72% able to be handled at home, avoiding costly ambulance and Emergency
        Room (ER) trips. Even when the patient is seen in the ER and hospitalized, studies show that
        the hospital stay for those whose admission included a call to a Poison Center was on average
        3 days shorter than those in-patients whose medical case had not utilized Poison Center
        consultation.

        Poison Centers are managed medical care delivery systems; these are not “call taking centers”
        in the usual sense, because health care is being delivered under the license of a Medical
        Director. This places specific requirements on the interaction of SPI staff and the Medical
        Director to assure quality health care delivery. The TPCN staff in FY 2010 consisted of 82.8
        FTEs overall, with 62.3 being funded through State funds. This includes but is not limited to 3.25
        Medical Directors, 8 Educators, and 57.8 SPIs and C-SPIs not all of which are paid through
        CSEC grants. AAPCC accreditation is based in part on staffing per total population served and
        human exposure calls handled (see Appendix A) which creates basic requirements for adequate
        Center staffing of both SPIs and oversight Medical Directors. Each Center in the TPCN is
        staffed differently according to its needs. These data are provided with the caution that one
        cannot evaluate each Center solely based on “call-taking” since they are each health care
        delivery entities.

        There would be difficulty in re-locating C-SPIs and, as a result, meeting staffing needs for these
        highly qualified positions would require alternative solutions, such as working remotely or in
        “satellite” locations; this also requires significant transition time for any system change to assure
        continuation of necessary staffing. This assumption is based on Texas’ experience with filling
        vacancies in these positions as they arise, as well as the experience of two comparable states,
        New York and California, who have undergone consolidations in recent years (Please see
        Appendix G to summarize the input from these two States). In Texas, we have experienced
        difficulty and delay in filling vacancies. Since SPIs/C-SPIs are highly qualified individuals with
        higher degrees, the TPCN competes with the health care industry to hire from a limited pool.
        CSEC conducted a survey of current SPI staff and the overwhelming response was that they
        would choose to work in a “remote” capacity, stay with their institution in a different non-SPI
        capacity, or they would look locally for work, rather than physically relocate. This is not
        surprising since the current economic environment does not lend itself to relocation when local
        jobs are available. Further disincentives to relocating include the potential non-competitive pay
        rate and the often less desirable work schedules offered through the TPCN. In addition, the loss
        of seniority with a Host Institution, compensation, and retirement plans, health insurance,

CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                          33
        relocation of children in school and the need to sell a home in a difficult real estate market,
        provide strong disincentives to relocation for professional staff.

        Based on experience, the TPCN managers estimate that it takes, at a minimum, approximately
        2 years to replace the loss of one highly qualified C-SPI to regain the same level of accuracy,
        functionality, and efficiency. In the experience of New York and California, highly qualified RNs
        and PharmDs elected to remain with their host institution or seek other local employment rather
        than re-locate to continue work as a C-SPI, because of their ability to acquire work in their high
        demand professions within the current health care system locally.

        One option to avoid relocation is to create more “Remote” (e.g. work off-site) agents or a
        “satellite” system of centers serving as “sub-stations” to fully staffed Centers. There are
        limitations to the use of these options; including potential and real additional incurred costs (see
        Appendix C).




CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                         34
                                                                                         APPENDIX - G
        EXPERIENCE OF NEW YORK AND CALIFORNIA STATE POISON PROGRAMS
        The following information is offered based on telephonic conversations on multiple occasions with both
        State Directors, but most recently with Michele Caliva, RN C-SPI, Administrative Director, Central New
        York Regional Poison Control Center, Syracuse, NY on 1-12-2011 and Dr. Stuart Heard, PharmD.,
        FCSHP, Executive Director, California Poison Control System on 1-13-2011.

             New York: As of the fall of 2010, New York State is undergoing a fiscally required downsizing of the
        Poison program from 5 to 2 Centers. The Syracuse Center took over responsibility for the Buffalo (2.5-3
        hours travel time) and Rochester (1 hour travel time) areas. Those two centers had employed 12.5 SPIs,
        of which none elected to move to the Syracuse Center. To maintain the expertise needed for the NY
        system, eight SPIs were offered the option of working remotely from their home. They are currently
        required to travel to the Syracuse Center to work 8-16 hours per month, although the Center Director has
        stated that it is already apparent that up to one week of on-site work per month may be required to meet
        training and supervisory requirements. They remain in transition with determining the best operational
        details of the system.

            California underwent a consolidation of its Poison Program in the mid 1990’s. California had 14
        Poison Centers that had decreased to 7 by the early 1990’s; these centers were under various
        management including County government, State, and Medical Center governance. In the early 1990’s
        the State released an RFP for a single Poison Center contract. UC-San Francisco won that bid and
        moved to consolidate the 7 Centers to 4 centers distributed around the State (San Francisco; Fresno;
        Sacramento and San Diego); all workers became UCSF employees. To manage this transition while
        maintaining services, UCSF found that they needed to:

                •   Move to a “skills mix model” wherein they hired more uncertified staff for the interim;
                •   Found most success in recruiting locally;
                •   Were able to move one C-SPI from LA County to San Diego County;
                •   Were able to achieve “system certification” so that all 4 Centers did not require full staffing
                    24/7 (the State functions on only 2 C-SPIs per night shift);
                •   Found much push-back from staff moving due to non-transportability of tenure and other
                    benefits; lost at least 8-9 highly trained SPIs due to this factor;
                •   Found the need to add costs due to “build out” to add staff, moving costs, rent space,
                    facilitation of new hires and significant costs incurred to train new staff;
                •   Lost at least 5 Pharmacist SPIs who elected to remain with their City/County employment;
                    replaced 3-4 Pharmacists with new hires requiring new SPI certification;
                •   Entered into new contracts to pay M.D.s willing to oversee operations to meet certification but
                    not willing to move affiliation.

        Overall, Dr. Heard stated “It took 5-7 years to break even in operating costs in order to save the 5 slots
        we cut. Medical people will not move; there are too many other options for them.” He assesses the major
        savings as coming through the move to “mixed use” staffing. He also has conducted an informal study on
        the return on investment, and the overall conclusion is that the move saved approximately $500,000, not
        accounting for staff time to operationalize the transition. He emphasized the value of in-kind contributions
        from Host institutions; that the only savings were in cutting staff positions, which were partially off-set by
        the loss of Institution support; that there is a significant transition period; that maintaining Centers to
        provide Toxicology training to Emergency Room residents and Toxicology Fellows is critical; that System
        Certification to “look like one Entity” was critical to any savings they achieved.




CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011
                                                                                                                  35
                                                                                      APPENDIX – H
          IMPACT OF PROPOSED APPROPRIATION FOR FY 2012-13



                                                                            FTE
  CHANGES NEEDED TO MEET                                                   CUTS
       REDUCTIONS                     FY 2012    FY 2013      BIENNIUM                                COMMENTS

(1) Freeze staff salaries                                                          $ 0 reductions; Impact = staff retention.
(2) Eliminate Indirect                                                             TBD - dependent upon host institutions
(3) Reduce/Limit Fringe                                                            TBD - dependent upon host institutions
(4) Change model for Info calls        $10,000     $10,000      $20,000            Replace 1 SPI FTE with 2 Student FTEs
(5) Change model for low acuity                                                    Replace 1 SPI FTE with 2 non-SPI FTE
calls                                  $10,000     $10,000      $20,000            (pharmacy techs, paramedics, etc.)

                                                                                   Based on average call taker salary of $78,650.
                                                                                   Impact = Maximum of human exposure calls
                                                                                   that could be handled = 215,200. Number of
                                                                                   human exposure calls in FY 2010 = 181,151.
(6) Network Scheduling of SPIs will                                                Assumes a 6-month transition to network
reduce FTEs                           $231,996    $550,000     $781,996     7.00   scheduling in the first year.


(7) Eliminate animal exposure calls   $103,177    $103,177     $206,354     1.35   Impact = minimal

                                                                                   92,884 Pill ID calls in FY2010; 16,801 were
                                                                                   from law enforcement.                Impact =
                                                                                   loss of service to law enforcement, schools and
(8) Eliminate Pill ID Calls           $626,054    $626,054    $1,252,108    7.96   elderly & prevention of drug reactions/suicide.


                                                                                   Impact = loss of SPI FTEs limits the number of
Reductions                            $981,227   $1,299,231   $2,280,458   16.31   Poison Control Calls that can be processed.




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