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ACB-CLIN-CHEM-GEN  1998

ACB-CLIN-CHEM-GEN 1998

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Subject:

NPIS

From:

"bob.flanagan" <[log in to unmask]>

Reply-To:

bob.flanagan

Date:

Wed, 9 Dec 1998 12:46:31 +0000

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (102 lines)


We write in response to Doug Hirst's note on requests for analyses
reportedly following advice from the NPIS and subsequent comments.

The NPIS currently deals with some 250,000 calls per annum. There are 7
centres (London (Guy's), Birmingham, Newcastle, Leeds, Cardiff,
Edinburgh, and Belfast). Leeds is due to merge with Newcastle in the
near future. The service is, in the main, paid for out of central funds.
At peak times (between about 20.00 and 02.00) an information officer at
the London centre will deal with 20 enquiries per hour. Details of each
call, including any suggested treatment, are recorded. Audit is carried
out. A "clinical standards group" reviews the quality/relevance of the
advice given.

Responsibility for the care of the patient remains that of the clinician
looking after the patient. The clinician must justify any requests for
analyses on the basis that they will influence the care of the patient.
The NPIS must perforce offer best available advice based on current
thinking otherwise they themselves might be considered negligent. This
being said the NPIS is always cautious about recommending emergency
analyses in general, and emergency toxicological analyses in particular,
and this has been emphasised in many publications associated with this
Unit over the years (see, for example, Simple tests to detect poisoning.
J Clin Pathol 1988;41:996-1004 and Basic analytical toxicology. WHO,
Geneva, 1995).

As regards Doug Hirst's question about urgent T3 and T4 assays, it would
appear that the London centre was indeed contacted about the patient in
question. However, from our records it seems that T3 and T4 assays were
NOT recommended, only mentioned as possible indicators of exposure which
could be measured if required in the management of a very sick patient

This illustrates one problem: how to ensure that NPIS advice is recorded
correctly by the user and that appropriate action is taken. The NPIS
emphasis is to try to stop second/third hand accounts and when possible
give information directly to the clinician looking after the patient,
i.e. to establish clear lines of communication. Obviously Path Labs need
to do the same. How can the lab check that the interpretation made by
the doctor is in line with the information given out by the NPIS? Well,
in addition to publications/textbooks, many hospitals in Scotland and
Northern Ireland  and about 50 % in England have access to the NPIS
TOXBASE system which allows on-line viewing of the NPIS Poisons
Information database.

TOXBASE is an on-line database and is currently in viewdata format. Any
NHS professional can register free of charge. If a PC with Windows 95
and a modem is available the only cost is that of a local phone call.
During 1999 TOXBASE will change to be available via the internet, NHSnet
and possibly, for some users, CD-Rom. For further information or to
register please contact:

e-mail: [log in to unmask]
phone: 0131 536 2298/2303
post: Scottish Poisons Information Bureau, The Royal Infirmary,
Edinburgh EH3 9YW

The second problem is that of the non-availability of urgent assays
which may be required to give the clinician the best service. The
classic examples here are methanol and ethylene glycol. Clearly the
clinician must be made aware of the potential value of these assays, but
the advice must be realistic in view of what is actually available. The
NPIS does try to be realistic, but how this is translated into demands
on local services is unknown. By analogy with orphan drugs, we think of
these assays as orphan toxicological analyses - so little used as never
to be viable on a cost/test basis, but potentially extremely valuable in
certain circumstances. Our own laboratory receives no central funding
and we use funds from more profitable/larger volume services to
subsidise "orphan" assays, but this does not extend to a full out-of-
hours service for these analytes.

TOXBASE includes lists of analyses available from Belfast, Birmingham,
Edinburgh, Glasgow, and London with advice on who to contact to arrange
assays. If an emergency analysis is not available then follow Robert
Forrest's advice - get the appropriate samples collected and offer to
arrange the analysis at the earliest opportunity if patient care might
be influenced, otherwise store the samples in case an analysis might be
useful in retrospect.

Finally, colleagues might like to know that there is currently a
restructuring of the NPIS across the UK with a new management board
which includes A+E consultants, a paediatrician, and a GP in addition to
the NPIS directors. It might be sensible to have a clinical chemist or
other lab-aware person on the board as well. We would be grateful for
your comments. It would also be helpful if colleagues would send us
([log in to unmask]) details of problems they encounter in providing
laboratory services for poisoned patients, including, if possible, the
date and time of any enquiry to the NPIS, a statement of the advice
given and from which NPIS centre the advice originated.

Glyn Volans, Director
Nick Edwards, Manager NPIS (London)
Bob Flanagan, Consultant Biochemist
Medical Toxicology Unit
Avonley Road
London SE14 5ER
Tel: +44 171 771 5365
Fax: +44 171 771 5363
e-mail: [log in to unmask]


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