By Dr Yasser Sharif,
Dr Rania Al Dweik,
Inadequate hospital stocks and the unavailability of essential antidotes is a worldwide problem with potentially disastrous situations for poisoned patients. Most poisoned patients can be managed successfully with gastric decontamination and supportive care; however, for some patients, timely administration of the correct antidote is essential to minimize morbidity or prevent deaths.
The treatment of digoxin induced arrhythmias with digoxin immune Fab antibody fragments is a specific example in which a delay in antidote administration may prove fatal.2 Despite the effectiveness of digoxin immune Fab, a recent survey of 108 hospitals in the Unites States found that only 2% stocked enough of the antidote to treat a single severe adult poisoning.
In 2000, the first US consensus guidelines were published, providing direction for hospitals regarding which antidotes were necessary to stock and the quantity recommended.4 Shortly thereafter, investigators in British Columbia, Quebec and Ontario evaluated the adequacy of antidote stocking in Canadian hospitals. Although they applied different criteria, all three studies reported gross inadequacies in antidote stocking.
The precise cause of this serious problem is unknown but appears to be related to limited hospital resources.5, 6 Other possible causes are the costs of antidotes, as well as pharmacist and physician unfamiliarity with antidotes. The Joint Commission on Accreditation of Healthcare Organizations requires that hospitals stock antidotes, but does not provide specific requirements.
The Emirate of Abu Dhabi encompasses a relatively vast geographical area compared to other emirates in the UAE. These geographic factors add to the difficulty of moving patients or antidotes from one hospital to another. This means that even a small centre may be required to treat an acutely ill, poisoned patient, for several hours using only in-hospital supplies.
In light of all these facts, the Poison and Drug Information Center – Health Authority Abu Dhabi (HAAD) took the initiative to conduct a comprehensive survey in order to determine whether the problem of inadequate antidote supplies exists within the hospital system in the Emirate of Abu Dhabi. The aim of this study was to determine the adequacy of antidote stocks in the Emirate of Abu Dhabi hospitals which have emergency room departments.
We conducted a prospective observational study in the Emirate of Abu Dhabi hospitals. HAAD Facility Licensing Department provided a list of all potentially eligible hospitals for the survey. Twenty six eligible hospitals were defined as any hospital that had an emergency room, inpatient beds and could be required to treat an acutely poisoned patient. Medical centres, clinics and military hospitals were excluded.
Data was collected using a two-part survey instrument. Part 1 captured demographics including hospital size, number of ER beds and ER visits in 2009, number of poison cases, pharmacy operation hours on weekdays and weekends, whether the hospital has an agreement with another hospital for sharing antidote, and whether they have internal guidelines or protocols in regard to antidote stocking.
Part 2 captured dosage form, strength and quantity of all 38 antidotes outlined in the HAAD Poison and Drug Information Center antidote list. All surveys were sent by email on 31 May 2009. This was followed by reminder email to non-responders on 9 October 2009. A third and final contact attempt with non-responders was conducted by telephone on 1 November 2009. Responses were accepted by email (our preferred method), mail, fax or telephone.
Data were entered into an Excel 2007 (Microsoft) database and imported to SPSS statistical software (ver. 17.0 Windows) for analysis. Standard descriptive statistics were reported including means and standard deviations. The adequacy of antidote supply for each hospital was reported as a raw number and proportion of essential antidotes stocked. The overall proportion of hospitals stocking an adequate supply of each individual antidote was also determined. Overall comparison of the mean number of antidotes adequately stocked between various hospital sizes was performed using a one-way analysis of variance (ANOVA) with 95% CI. Two-group comparisons of the mean number of antidotes available between 2 priori-defined hospital categories were made using a 2-tailed student’s t test. No adjustments were made for multiple comparisons.
Twenty six potentially eligible hospitals were identified and asked to participate in the survey. Following the initial mailing, only data from the 20 hospitals (77%) that responded were included in the final analysis.
2. Hospital Characteristics
Fifteen (75%) of the hospitals were classified as urban while 25% (5) were rural. (Urban; hospitals serving populations >20,000; Rural; hospital serving populations <20,000). The ER size (Small ER size [1-15 bed], Medium ER size [16-30] bed and Large ER size bed [31-45] was varied between small (65%), medium (25%), and large (10%). Most of the hospitals (95%) did not have an antidote sharing policy with other hospitals; also 75% of the hospitals did not have antidote stocking guidelines.
3. Antidote Stock Deficiency
Abu Dhabi hospitals had adequately stocked a mean of 10.5 ± 7.5 antidotes from the 38 antidotes surveyed.
3.1 Stocking Deficiency in Essential Antidotes
Only 10% (2) of hospitals adequately
stocked all 12 essential antidotes. Essential
antidotes are antidotes that should be immediately
available in ER or any area where
poisoned patients are initially treated.
Table 1 shows that:
● Calcium gluconate injection was the only antidote adequately stocked in all surveyed hospitals. ● 70% of hospitals had adequate stocks of diazepam and sodium bicarbonate. ● 30 -50% of hospitals had adequate stock of flumazenil, methylene blue, and NAcetylcysteine. ● 20% of hospitals had adequate stock of atropine sulfate, cyanide antidote kit, glucagon, naloxone, and phentolamine mesylate. ● None of the hospital stocked calcium gluconate gel (0%).
Table 2 shows that:
● 85% of the hospitals adequately stocked phytonadione (vitamin k1). ● 40 - 60% of the hospitals adequately stocked folinic acid (leucovorin calcium), octreotide acetate, and protamine sulfate. ● 10 -20% of the hospitals adequately stocked cyproheptadine, dantrolene sodium, digoxin immune fab, ethanol, pralidoxime chloride, pyrdoxine and snake antivenom. ● Only 5% the hospitals adequately stocked fomepizole.
Table 3 shows that:
Antidotes are therapeutic agents intended to modify or counteract the clinical effects of particular toxic substances in the human body; antidote availability may often be life saving for poisoned individuals. 7 Delayed use or unavailability of antidotes could result in catastrophic consequences. 8 In cyanide poisoning, for example, the lack of prompt antidote treatment with nitrite and thiosulfate may result in anoxic brain injury or death.
The definition of how much antidote is adequate is debatable. We purposely selected amounts that might be needed to treat a 70 kg patient during the first 24 hours.
Our survey of acute care hospitals in the Emirate of Abu Dhabi revealed that many poisoning antidotes are not stocked in adequate quantities for the initial treatment of even one case of severe poisoning. Of the 12 ‘essential antidotes’ that were evaluated, the only antidote stocked adequately was calcium gluconate injection, the medication that must be available at any emergency, not because of its use as antidote, but for other lifesaving conditions.
In contrast, over half of the hospitals did not stock cyanide antidote and over half of the hospitals had insufficient supplies of atropine sulfate (patients with severe cholinergic syndrome from organophosphate or carbamate insecticide poisoning are likely to die from respiratory failure without the early institution of atropine).
Ninety-five percent of respondents indicated that no antidote sharing policy existed with nearby hospitals, and also no guidelines were identified for antidote stocking at those hospitals. For a patient with serious digoxin-induced arrhythmias, even 30 minutes spent procuring the antidote could prove fatal. Only 15% of surveyed hospitals stocked an adequate amount of digoxin antidote (Digibind).
Several factors are associated with adequacy of antidote stocking. Specifically, inadequate stocking was more common in smaller (<15 beds) (8.7 ± 6.0 antidote) hospitals and in rural hospitals (5.8 ± 2.8).
The availability and quantities of antidotes in Abu Dhabi hospitals were not in accordance with international recommendations and guidelines. Despite that, it is not considered a drawback for certain hospitals not to have all antidotes, because of the nature of the medical service they provide. Furthermore, the guidelines by which we compared the stocking of antidotes followed those implemented in USA, Canada and UK. The nature of poisoning cases in Abu Dhabi might be different than those observed in the USA, Canada and UK.
Since the timely use of antidotes is potentially lifesaving in certain poisonings, maintaining a sufficient stock of antidotes is the responsibility of any facility that provides emergency care. If a poisoned patient requires an antidote that is not stocked at a particular hospital, then either the patient must be transferred to a facility where the antidote exists or the antidote must be obtained from another hospital.
Health Authority-Abu Dhabi as a regulatory body is working on a policy to mandate notification of poison cases from all healthcare facilities (HCF) with ER departments. Two lists will be mandated according to the hospital size with a minimum stock amount of each antidote that should be available at HCF to treat 70 kg adult for the first 24 hours. The basic list will be mandated on the private sector and the advance on public hospitals.
Also within the policy, HCF with ER departments must create their own antidote sharing policy. A monthly report of each antidote stock level at Abu Dhabi HCF with ER departments must be submitted to the Poison & Drug Information Center at HAAD. A follow-up survey will be conducted after 18 months to re-evaluate the antidote stocking at HCF to check whether they comply with the recommendations and policy.
The authors Dr Yasser Sharif is head, Medication & Medical Product Safety at the Health Authority - Abu Dhabi. He can be contacted by e-mail: firstname.lastname@example.org Dr Rania Al Dweik is Poison and Drug Information Officer, HAAD Dr Kefah Al Qawasme is Poison and Drug Information Officer, HAAD
Copyright © 2011 MiddleEastHealthMag.com. All Rights Reserved.