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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 6 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 11 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. CSEC ▪ REPORT ON TEXAS POISON CONTROL NETWORK ▪ FEBRUARY 2011 36
"Report on the Texas Poison Control Network"