Experience of Indian emergency physicians in management of acute poisonings

Abstract Indian Emergency Departments (EDs) encounter a significant number of toxicologic cases each year, approximately half of which are attempts at deliberate self-harm. The objective of this study was to understand trends in the presentation and use of resources for the treatment of poisonings in the emergency department setting. Between September 2015 and May 2016, we administered an online survey to Indian emergency department (ED) physicians. We queried respondents about common poisonings, treatments, and educational resources, including use of Indian poison centers. A total of 152 individuals responded to the survey. Respondents living in the eastern (64% of respondents) and southern (57% of respondents) regions of India were most likely to report not having a poison center as compared to respondents from the north. Most physicians instead used hospital protocols, textbooks, or online resources to guide treatment and education efforts. Despite frequent presentations of potentially life-threatening ingestions, often EDs do not rely on extensive poison center consultation. Although India has a poison center hotline, most physicians in the south and east were unaware of this resource, suggesting an opportunity for better physician education.


Introduction
Toxic ingestions, both intentional and unintentional, represent a significant public health issue worldwide [1]. In India, poisoning leads to significant morbidity and mortality each year. The number of total poisonings that occur in India each year is difficult to quantify since these events are widely unreported and most prior studies have focused on regional data. According to the National Crime Records Bureau of India, there were 27,657 deaths and suicides by poisoning in 2015 [2,3]. The World Health Organization estimates that India's mortality rate from poisonings is 31.3 per 100,000 individuals [3]. Intentional overdoses cause more than half of acute poisoning cases in India [4]. According to a ten-year analysis of data from the National Poisons Centre of India, the most common poisonings in India involve the use of household products, followed by pharmaceuticals, pesticides, and industrial chemicals [5].
A number of studies have addressed the epidemiology of poisonings in India with data largely derived from hospitals or poison centers . Most of the studies published have focused on describing the distribution of cases by region or demographic group. Few studies have examined approaches to poisoning treatment by physicians in the emergency department (ED) setting. Emergency physicians frequently provide the initial evaluation and management of acute poisonings. In the United States, for example, there are over 1 million annual visits to the ED for poisonings (CDC) [28]. India lacks similar published data for ED visits for poisonings. However, given the burden of disease, this is likely a common occurrence. Emergency physicians may need to rely on a wide variety of reference tools to manage such poisonings, especially for the treatment of ingestions by substances infrequently encountered. However, the types of resources used by Indian emergency physicians to aid in the management of acute poisoning is largely unknown.
Our objective was to understand the poisonings physicians working in Indian Emergency Departments frequently encounter. In addition, we sought to describe the educational tools used in the acute care setting to assist in the management of poisonings by physicians in India.

Methods
We designed a survey of emergency physicians in India to assess their experiences and resources of managing poisoned patients. We developed and piloted the survey with a group of emergency physicians and international toxicology experts, and we modified it based on feedback received. The George Washington University Institutional Review Board reviewed and determined the study to be exempt from consent.
We distributed the survey to emergency department physicians in India between November 2015 and May 2016. We recruited respondents for the survey via two methods: (1) recruitment via existing email databases (email distribution list for an emergency medicine conference and database of emergency medicine residency graduates) and (2) inperson recruitment at a national emergency medicine conference in India (cards containing the link to the online survey were distributed at the conference). We collected data online via SurveyMonkey.com, an internet-based survey data collection tool. We offered participants the chance to enter a raffle of a toxicology textbook as an incentive for participation in the study. We included participants at all levels of practice including attending level physicians (consultants, which are the most senior attending level trained physicians), junior consultants (who have completed training and operate at the attending level but are less senior), registrars (physicians who have recently completed training), and post-graduate trainees (physicians in residency training). Our email list had 1522 email addresses, however some of these emails represented alternate contacts for the same person.
We queried respondents about their experiences with poisonings presenting to emergency departments in India. We asked them to select the five most common poisonings from a list of those poisons that had been commonly reported from prior Indian literature . We also asked respondents about what resources they commonly used in making treatment decisions. Specifically, we asked whether participants used a textbook (emergency medicine and/or toxicology), internet resources (social media/free online access medical education materials [FOAM], online and/or smartphone content), hospital consultants, or poison center/toxicologist consultation. Respondents could select more than one resource. We collected demographic data about the physician completing the survey, including the number of years in practice since completion of medical school (grouped into 0-5, 6-10, and 11 or more years), level of training (consultant, junior consultant, registrar, or post-graduate trainee) as well as information about the clinical practice setting, including state (divided into south, west and east and north regions), size of the hospital in which he/she practiced (<350 beds, !350 beds) and the urbanity and size of the practice location (rural, surburban or small city versus medium or large city).
First, we evaluated our sample demographics and the distribution of the most common poisonings encountered. Next, we reported mean percentages of respondents reporting use of specific types of resources for the acute management of poisonings.
Finally, we explored the limitations reported on the use of a poison center as a treatment resource. Specifically, we asked respondents to identify any limitations to accessing a poison center or toxicologist (lack of a poison center in area, limited poison center hours, perception that the poison center was not useful, or belief that a call to a poison center would take too long). We analyzed data using STATA Version 13.1.

Demographics of physicians
A total of 152 respondents completed the survey. Based on our email list, this was a response rate of 10%. Because some of our emails were duplicates, and because we could not track links accessed through social media, the exact response rate was likely higher than 10%. Demographics appear in Table 1. Over half (51%) of respondents were post-graduate trainees (n ¼ 78), 22% were consultants (n ¼ 24), 11% were junior consultants (n ¼ 16), and 14% were registrars (n ¼ 21). The majority of respondents (61% or n ¼ 92 respondents) had been in practice for 0-5 years since the completion of medical school.

Frequency of poisonings
Most respondents relied on the use of either emergency medicine or toxicology textbooks as sources to aid in the acute treatment of poisonings, with 71% of respondents using these materials (see Table 1). Respondents also frequently used internet resources such as those available through online web searches, social media, and/or FOAM as well as through smartphones (69% of respondents). Fifty-one percent of respondents used hospital consultants. Respondents were least likely to use poison centers, with only 23% of all respondents stating that they used this as a regular resource. Persons with 0-5 and 6-10 years of practice were significantly less likely to use poison centers as compared to the use of textbooks and online resources. Consultants, registrars, and trainees were also more likely to report the use of online sources and textbooks rather than poison center use. By region, individuals in the north (80%) were much more likely to use poison centers than other regions. Individuals in the south were least likely to use poison centers, with only 8% of respondents in this region using this resource (see Table 1).
Respondents gave various reasons for the lack of use of poison centers. The most common reason reported was because there was no poison center available (44%, n ¼ 67). Almost 10% of respondents cited limited poison center hours (n ¼ 15), and 9% of respondents felt that the calls took too long to complete (n ¼ 14). By demographics, respondents living in the east (64% of respondents) and south (57% of respondents) were most likely to report not having a poison center as compared to respondents in the north ( Table 2).

Discussion
Our study showed a similar pattern of ingestions to previous work in India, with insecticides, sedatives and household cleaning agents as the most common causes of poisonings [4][5][6]18]. These poisonings are common in India due to the frequency of use and Table 1. Sample demographics and use of resources by demographic, hospital practice, and regional characteristics of respondents. ease of availability [4][5][6]18]. Many of these agents can have devastating clinical effects that require close monitoring and management. For example, organophophates are among the most frequent pesticides implicated in poisonings with a mortality rate of 10-20%, exacerbated especially with treatment delays [29][30][31]. Although many Indian physicians likely have extensive knowledge of the treatment of such agents, use of resources such as poison centers expedite evidence-based treatment.
Our study showed that textbooks and online resources play a major role in providing information  to help guide physicians in treatment decisions. The use of FOAM is increasingly popular in emergency medicine settings across the globe [32][33][34]. In a study of usage of 12 popular FOAM sites in 20 countries, India accounted for the fourth highest number of sessions initiated [35]. The use of FOAM in clinical practice is particularly attractive, especially when other resources may not be readily available [36]. Smartphones allow clinicians to have ready access to such content using local cellular networks, without the reliance on the physical availability of textbooks or internet connectivity in remote locations. Poison centers, although highly important in the treatment of poisonings across the globe, were less likely to be used in our sample population. Poison centers also serve other purposes, such as the provision of epidemiologic data used to track the number and type of posionings in a region. Poison centers can help guide policy decisions for prevention and can aid in the event of a public health threat that may involve a toxic substance [37]. Despite this potential, poison centers are still not universally used in the United States, despite data showing improved outcomes and cost savings [38]. In one study, about 67% of US primary care physicians and 99% of emergency physicians reported using a poison center in the past year but in only 50% of cases [39]. Globally, the World Health Organization reports that only 46% of its member states have poison centers (WHO) [40].
Our study showed low rates of use of poison centers in our sample, especially in the south of India. Poison centers in India are not as widely distributed as they are in the United States, which has over 55 poison centers in existence today, each providing support for callers anywhere in the country [41]. According to the World Health Organization, as of September 2017, there were a total of 6 poison centers located in India; one national poison center in the north (Delhi), as well as 5 regional centerstwo in the west (Gujarat) and three of which were in the south (Karnataka, Kerala, and Tamil Nadu) of India [40]. The All India Institute of Medical Sciences (AIIMS) runs the National Poisons Information Centre (NPIC), which operates 24 hours a day, 7 days a week, and provides a toll-free phone number available countrywide for consultation. Founded in 1995, NPIC is the oldest and most well established poison center in the country and is run by faculty trained in pharmacology and includes staffing by scientists and resident physicians [4,42]. Less information is available about the regional poison centers, however, three of these regional centers had 24-hour availability per the WHO website [40]. AIIMS has published a number of epidemiologic studies outlining the most common poisonings that have presented to Indian poison centers [4,5,43]. Historically, the AIIMS National Poisons Information Centre has seen relatively low rates of the use compared to use of poison centers in other countries, possibly due to medical legal issues or a lack of awareness of its availability [43]. For example, suicide was illegal in India until 2017. As a result, families may be less likely to report intentional ingestions due to fear of further investigation as a criminal activity [44,45]. It is unclear how physicians nationwide use this poison center, or whether physicians are more likely to use the regional poison information centers reported by the WHO. In our study, respondents from the south had the lowest rates of the use of poison centers, with only 8% using them as a resource. Although these respondents were from states that also had regional poison centers, the scope and catchment area of such centers is unknown. Although an Indian state may have a poison center, physicians not located in the same city as the center may be less likely to use it or unfamiliar with its existence or capacity.
This study had a number of limitations. It included a small sample of physicians, and our survey response rate was low. We collected respondents from samples of physicians who attended conferences, who completed emergency medicine training or who used email. As a result, we may have had a response bias with our respondents being younger or having access to online resources as compared to non-respondents. Because of the sample size and sample characteristics, we may have not captured information generalizable to India as a whole. The study used self-reported data, rather than the use of chart review to confirm the epidemiology about the distribution of poisonings reported by survey respondents. Although there is a national poison center in India, we do not have information about the characteristics of the regional poison centers in each state so we cannot evaluate the relationship of staffing, hours, fees, or catchment area to the use and perceived utility of such centers by emergency medicine physicians.

Conclusion
Our study highlights physician perspectives on the frequency and treatment of poisonings in India. Despite the availability of poison centers in India, emergency medicine physicians rarely use this resource in the management of acute poisonings. Indian emergency physicians have extensive experience with poisonings, but they need better access to and education about the scope and availability of Poison Control Centers Future studies should focus on how the use of resources affect physician comfort level with the treatment of poisoning as well as the clinical outcomes of presenting cases.

Disclosure statement
No potential conflict of interest was reported by the authors.