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Ian M Whyte, Andrew H Dawson, Nicholas A Buckley, Gregory L Carter and Catherine M Levey
Readers' comments with reply from author added Thursday 22 May.
Further readers' comments with reply from author and extra text for article added Thursday 29 May.
The authors might also consider a further paper looking at what has happened to DSP patients at 6/12 and 12/1, after discharge from the service.
The disadvantage of consolidation (pg 17/27) ie- loss of skills, could be avoided by making it part of registrar training programs at all hospitals that they rotate through the acute toxicology unit for a set period of time.
[Authors' response: Point 1 concerning the number of readmissions of the same patients. We have added to table 1 an extra column indicating the number of patients responsible for the number of admissions. This shows the number of admissions that were due to repeat presentations by the same patient within the various subgroups.
We are indeed considering further papers looking at what has happened to DSP patients after discharge as well as assessing risk factors for representation.
The point about making rotation through the acute toxicology unit a part of registrar training has been included in the discussion.]
This paper describes the ten year experience of Australia's only comprehensive Clinical Toxicology (poisoning) Service. The service in Newcastle has already produced a considerable range of publications on various aspects of Clinical Toxicology, and has undoubtedly made a significant contribution to knowledge regarding the care of such patients. This paper documents the structure of the service, its philosophies and objectives and its overall results with respect to outcome measures such as mortality, disposition of patients, and average length of stay of patients. It also attempts to compare these outcome measures with state-wide and nation-wide statistics.
In general, I think the paper is important in that it is describing a significant contribution to the clinical care of an important patient group in Australia. However before it is published attention needs to be paid to the following important concerns:The paper is too long and is trying to focus on too many "messages". In my view, the major issues on which the paper should focus are the structure of the service, the results with respect to mortality and average length of stay, and the features the authors consider are most responsible for the success of their service. This latter point should also focus on the "transportability" of the service to other areas without the unique geographical features of the Hunter area.
The authors may choose to focus on other issues, but if they accept my recommendation, then pages 1 and 2 could be shortened a little, pages 4 and 5 simplified a little, pages 6-9 drastically shortened (probably to only a few paragraphs), pages 9-12 simplified a little (see below), and pages 12-16 simplified a little.
[Authors' response: We accept that the paper is too long and focusing on too many messages and have drastically reduced the size of the paper. Extensive editing along the lines suggested by the referee has reduced the length of the paper to 2552 words. To do this we have focussed on the structure of the service, the results with respect to mortality and average length of stay and the features we felt most responsible for the success of our service. We also discuss the "transportability" of the service to other areas.]
The outcomes described are difficult to interpret, and could be simplified. Comparison of the outcomes to New South Wales and national data is also complex, and clearly has significant limitations. These limitations are somewhat grudgingly acknowledged late in the Discussion but should be discussed more "up front". I have little doubt that the authors are correct that the average length of stay of patients admitted to their service is less than the New South Wales and national average (indeed with the concentration of resources they are providing to the service it would be extremely disappointing if this was not the case). However the authors still should not over-interpret their data and should more honestIy acknowledge its limitations.
[Authors' response: We have simplified the description of outcomes and removed one of the tables comparing our data to major teaching hospitals in NSW. We begin the discussion with an elaboration of the limitations of our data in order to be more "up front". To support our contention that our admission policy does not significantly change the thrust of our argument, we have included data on bed stay removing various subsets of patients that may not be admitted at other hospitals. The discussion has been modified appropriately.]
For instance, it is clear from the data given in the paragraph commencing at the bottom of page 11 that significantly more admissions occur in the Newcastle area than in the rest of New South Wales. In 1992 it is stated that there were 2,876 admissions in New South Wales, and 512 in Newcastle. The Hunter area does not have 20% of the NSW population, so either a lot more overdoses occur in Newcastle than in the rest of NSW, or there are clearly differences in the classification of patients. Thus the coding of the admissions in the rest of NSW may well be different from in Newcstle. Clearly this makes the comparative data suspect, and this should be more clearly acknowledged in the discussion - the issue is partially addressed at the bottom of page 13 and the top of page 14, but the possibility of different coding of complications or comorbidities, which I would have thought is a distinct possibility, is not mentioned. Obviously if this were to occur, then the author's argument tends to lose weight.
[Authors' response: Where it appears that significantly more admissions occur in the Newcastle area than the rest of NSW, we have addressed this in the discussion. In particular, we discuss the issue of different coding of patients between Newcastle and the rest of NSW.]
My suggestions for simplifying and focusing the results are: Table 2 is not necessary unless the authors wish to focus on this particular aspect of their service - my view is that this area of focus could be dispensed with. If Table 2 is eliminated, then paragraphs 2 and 3 on page 10 could be markedly shortened.
[Authors' response: We have removed Table 2 and consequently shortened paragraphs 2 and 3 and page 10 markedly.]
The paragraph commencing at the bottom of page 10 and finishing onpage 11 also is probably unnecessary. Longitudinal trends, with no comparator group, probably don't mean very much.
[Authors' response: We have left this paragraph discussing longitudinal trends as we believe it allows readers of the article to have some idea of the time course over which the reduction in bed stay occurred. This would give other area health services some information about the likely time period over which benefits may accrue after the institution of our model for the management of self poisoning.]
Are both Tables 4 and 5 necessary? In addition, in Table 4 the reference for the major New South Wales teaching hospitals' data comes from Newcastle Mater Misericordiae Hospital. It this the appropriate reference source? Similarly, the reference for the New South Wales public hospitals in Table 5 is from a Newcastle report.
[Authors' response: We have removed Table 4 and have adjusted the reference for the NSW Public Hospital Data in what was Table 5 and is now Table 3.]
In Table 3, which is probably the most relevant of the cornparator Tables, the reference for the national data gives a date of 1992, but the data is for 1991-1994. Is the national data strictly comparable with the Newcastle data? If not, the appropriate caveats should be given either as a footnote to the table or in the text.
[Authors' response: We have corrected the reference conflict pointed out by the referee. The data for the Hunter Area Toxicology Service is 1991-1994 inclusive and is compared with 1 year of national data from 1992. We have pointed out the problems associated with comparing data taken directly from our database with data from inpatient statistics collections in the discussion.]
The discussion on pages 13-16, whilst cogent, could be significantly shortened by focussing more on the key issues.
[Authors' response: We have significantly shortened and rearranged the discussion to focus more on the key issues raised by the referee.]
2. Describe the most important outcomes such as mortality and length of stay.
3. Discuss the "transportability" of the service.
4. In particular, address referee 2's (point 3) concern regarding classification of patients and referee 1's concern regarding readmissions of the same patient.
5. Please include a structured abstract in our preferred style (instructions attached).
6. Please reconsider your acknowledgements and forward to us signed permission to publish their names/statements from the persons you include in the acknowledgement section.
[Authors' response: As a result of this restructuring of our paper and following the guidelines of the referees, we believe that the manuscript now focuses on the current structure and practice of the unit including why it is so unique and what its most important features are. We describe the most important outcomes particularly mortality and length of stay and also discuss the transportability of the service. We have addressed in particular the issues regarding classification of patients and readmissions of the same patient.
We have rewritten the abstract to meet with your preferred style of
structured abstract and we have significantly revised our
acknowledgements.]
Readers' comments
The authors are to be congratulated for presenting one of the most
meaningful papers in toxicology in a long time. That data convincingly
demonstrate that specialized care is beneficial.The arguments are
strong, sound, and clinically relevant.
Clearly I would have accepted this paper had I been given it to review for any journal.
Robert S. Hoffman, MD, FACEP, FAACT
Director, NYC Poison Center
There is no comment in this article as to the time of day these patients were first admitted and how long before they were seen by a member of the team. Is it just like all traditional psych interest in self poisoning, only seeing patients during "comfort zone hours" or does someone senior see the patients early at admission?
John Stokes
[Author's response: We analysed time of overdose and of presentation to hospital for deliberate self poisoning in a previous publication in the journal as mentioned in paragraph 1 of this paper (Buckley NA, Whyte IM, Dawson AH. There are days ... and moons. Self-poisoning is not lunacy. Med J Aust 1993; 159: 786-9). That analysis showed that a pronounced circadian rhythm was evident. Peak time of overdose was in the early evening with presentation peaking a few hours later. Very few people poisoned themselves between 4 and 6 am. Over 50% of all admissions occurred in the 8 hours between 6pm and 2 am. Over 6 % of all admissions occurred in each of the hours between 6 pm and 1 am compared with less than 2% per hour between 5 am and 9 am.
In our service the longest possible time from admission to formal psychiatric assessment (psychiatric registrar, clinical nurse consultant or specialist) would be when the patient is admitted after 5 pm and seen the next morning at 8.30 am (15.5 hours). This would only be the case if the patient was consciously or cognitively impaired on presentation and therefore unable to be assessed, or able to be assessed but clearly needing to stay for medical treatment (e.g. paracetamol poisoning requiring N-acetylcysteine). Note that even when the patient is consciously or cognitively impaired, our practice is to begin the psychiatric assessment by obtaining a collateral history from family/friends and health care workers before proceeding with individual psychiatric assessment. This process routinely occurs 7 days a week with a regular morning psychiatric review of all deliberate self poisoning admissions and in practice the time from admission to psychiatric assessment is substantially shorter than 15 hours (although we have not formally analysed this).
In the event the patient presents with a toxicologically trivial poisoning after 5 pm or on weekends (which would allow discharge before the routine morning psychiatric review) then the psychiatric registrar on call will come in to do the assessment and decide on appropriate disposition. A specialist psychiatrist is directly available on weekdays and available on call after hours.
Dr Ian Whyte, Senior Specialist
Clinical Toxicology & Pharmacology
Further readers' comments
The following comments and queries are from Alan Wood, Psychiatrist, with responses from the authors:
Do the authors hold the view that the non metropolitan setting of the study has any inpact on its applicaction in the urban setting.
[Authors' response: As Newcastle is the 6th largest city in Australia we would regard our setting as primarily metropolitan/urban although we do provide a retrieval service and advice to rural areas. All major teaching hospitals in larger cities also have a rural area to which they rotate staff and provide a retrieval service.]
Will differing social contexts of the patients, urban metropolitan and rural, alter the outcomes. Does the population examined differ ( socio-economic demographics, family and community supports) from the DSP patients presenting to metropolitan hospitals?
[Authors' response: The area is considered to be socio-economically and demographically representative of Australia as a whole. In the absence of any clear description of deliberate self-poisoning patients from metropolitan areas that are larger than Newcastle it is difficult to ascertain how generalisable our study would be to specific areas which may have a high representation of a particular socio-economic or cultural group. This is unlikely to alter the outcomes that we have described in this paper but may influence other outcomes that we are currently studying such as re-presentation and use of other services.]
What are the advantages of inpatient stay over prompt assessment ( in hours, when staff are available, without extra call in costs), and intensive time limited community followup, where appropriate?
[Authors' response: In practice, those patients who arrive within hours and are medically fit for immediate or rapid discharge do receive prompt assessment and have community follow-up arranged. Such assessment is still intensive and requires considerable effort. One of the reasons for still admitting the patient is that the process helps to reinforce to the patient the concern that the team has regarding the deliberate selfpoisoning. Our patients often expect that, because they have a formal admission, they will need to be formally discharged. We have found this increases the compliance of both the patient and there family in the assessment.]
How was the cost of psychiatric and social work time calculated? Whilst doing this work they cannot have been able to perform other work, usually carried out by these services.
[Authors' response: This work reasonably forms part of the duties of both these professional groups. We admit that our policy of trying to assess all deliberate self-poisoning will generate more work than the traditional model. However, the rate of psychiatric diagnosis in this group appears to justify this approach.
When the service first started the Royal Newcastle (with existing psychiatric resources) there were only 217 deliberate self-poisoning admissions in 1987 and 235 in 1988. By the time the service moved to the Newcastle Mater Hospital and took on the area role (without an increase in resources) the numbers had increased to 353 in 1991 and 584 in 1995. Unfortunately this increase in work has impacted severely on the ability of our psychiatric service to provide its traditional role in liaison psychiatry with a resultant contraction in services to other patients in our hospital. The hospital needs another psychiatrist and psychiatric registrar to cover the standard role of clinical Liaison psychiatry and application has been made for enhancement. ]
How may patients were repeat consumers, more than usual or less?
[Authors' response: It is not possible to say if we had more or less repeat consumers as there are no data available from the Hunter area before our service began. However, we are very interested in this problem and it is the subject of a series of publications in preparation.]
Having said all of that I think any integrated and organised approach to DSP is an improvement to the usual "ad hoc" approach, particularly as the multidisciplinary approach andenthusiasm of the Authors will improve the quality of care offered to patients.
Alan Wood, Psychiatrist
In response to comments received on their article, the authors have added some further explanation of their practice to two paragraphs of the article; the additions are shown below in italic:
"HATS [Hunter Area Toxicology Service] medical management is provided by a full time equivalent clinical toxicologist (currently two clinical pharmacologists) and a registrar in clinical toxicology. The after hours service is provided by the two clinical pharmacologists with the addition of another clinical pharmacologist and a drug and alcohol specialist with an interest in toxicology. Every toxicology admission is seen by the medical team (at least once a day), seven days a week.
HATS psychiatric care is provided by a psychiatrist, a psychiatry registrar and a clinical nurse consultant in psychiatry. An after hours service is provided by part of an area roster of psychiatry registrars and four to six "second on call" psychiatrists. Every deliberate self-poisoning admission is seen by the psychiatry team (at least once a day), seven days a week. Even when the patient is consciously or cognitively impaired, our practice is to begin the psychiatric assessment by obtaining a collateral history from family/friends and health care workers before proceeding with individual psychiatric assessment. In the event the patient presents with a toxicologically trivial poisoning after 5 pm or on weekends (which would allow discharge before the routine morning psychiatric review) then the psychiatric registrar on call will come in to do the assessment and decide on appropriate discharge destination."
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