Volume 167 Issue 3

Antibiotic use in the Australian community, 1990-1995 Peter McManus, M Leigh Hammond, Susan D Whicker, John G Primrose, Andrea Mant and Steven R Fairall For editorial comment see Turnidge Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Abstract - Introduction - Methods - Results - International comparisons of antibiotic usage - Types of antibiotics used in Australia and indications - Discussion - Acknowledgement - References - Authors' details Make a comment - - ©MJA1997 Abstract Objective: To determine the pattern of antibiotic use in the Australian community, 1990-1995, and compare it with the pattern in other developed countries. Design: Survey of data from the national database on drugs dispensed in Australia (1990-1995), an international database on retail drug sales (1985-1994), and Australian prescriber surveys (1994, 1995). Main outcome measures: National and international retail sales of oral antibiotics (defined daily doses [DDDs]/1000 population/day) and antibiotic prescriptions dispensed through community pharmacies by drug type; antibiotic prescribing profiles for common conditions. Results: Antibiotic use in Australia remained steady between 1990 and 1995, with an estimated 24.7 DDDs/1000 population/day dispensed through community pharmacies in 1990 and 24.8 DDDs/1000 population/day in 1995. Amoxycillin, although declining in use, remained the most dispensed antibiotic. Compared with the other countries surveyed, Australia had the highest percentage use of tetracyclines, such as doxycycline, and the lowest percentage use of fluoroquinolones. Use of trimethoprim-sulfamethoxazole and flucloxacillin declined in Australia. In new cases of upper respiratory tract infection or pharyngitis, an antibiotic prescription was recorded for 57% of urban patient encounters and 73% of rural patient encounters. Conclusions: Antibiotic use in Australia is high, as in many other developed countries, but did not increase between 1990 and 1995. The overall profile of antibiotic use in Australia by drug class was similar to that in the United Kingdom. Antibiotics were still commonly prescribed for upper respiratory tract infection (which is usually viral), more commonly by rural than by urban general practitioners. MJA 1997; 167: 124-127 Introduction Patterns of antibiotic prescribing in Australia between 1987 and 1989 were reported previously by the Drug Utilization Sub-Committee (DUSC) of the Pharmaceutical Benefits Advisory Committee, Department of Health and Family Services.1 At the time, the Sub-Committee expressed concern over evidence of "inappropriate and unnecessarily expensive" practice, which was "directed too heavily towards the use of broad spectrum agents and newer more expensive drugs".1 To update these data, DUSC convened a working group in 1995, comprising representatives of DUSC, the Australian Pharmaceutical Manufacturers Association and the Therapeutics Resource and Educational Network for Doctors (TREND) project of the Royal Australian College of General Practitioners. This group reviewed Australian and international data on antibiotic sales and dispensing to determine patterns of antibiotic use in Australia between 1990 and 1995, and to compare these with patterns in similar developed countries. To understand trends in drug use, the group also analysed prescriber surveys of the indications for antibiotic use. Methods Data were derived from four sources: Prescription dispensing data: These were obtained from the database maintained by the DUSC secretariat which monitors dispensing of prescription medicines through community pharmacies in Australia. These data include dispensing to some private hospitals, but not public hospitals. The database contains information on all subsidised prescriptions processed by the Health Insurance Commission, together with an estimate of non-subsidised prescriptions from an ongoing survey of a sample of about 250 community pharmacies.2 Measurement units are either prescription volumes or number of defined daily doses (DDDs)/1000 population/day. The DDD is based on the assumed average daily dose of the drug when used for its main indication by adults. It is the unit approved by the World Health Organization for drug use studies and allows for comparisons independent of differences in price, preparation and quantity per prescription.3 Sales data: Data on sales of oral antibiotics to retail and hospital markets in a number of countries were obtained from Intercontinental Medical Statistics (IMS), Melbourne. This is a commercial market research organisation which collects sales data and surveys general practitioner (GP) prescribing in 33 countries.4 Data were retrieved as unit sales by form and strength and drug class and then converted to DDDs/1000 population/day. Prescriber survey: Diagnoses for which patients were prescribed anti biotics and patient ages were obtained from the Australian Medical Index (AMI), the survey of GP prescribing conducted by IMS. This uses a sample of 420 GPs stratified in line with the total Australian GP population by metropolitan/country location, age, year of graduation, and practice size (patient numbers). These GPs record all patient encounters over seven consecutive days in each quarterly survey period. The data are then projected to obtain quarterly estimates of prescribing patterns by diagnosis and by patient age and sex for the Australian GP population. At the end of a four-quarter cycle, GPs are invited to continue participating. About half agree, and the remainder are replaced by new recruits. As GPs start in various quarters of the year, there is continual turnover; GPs are not usually kept in the survey for more than two years. TREND project: Use of antibiotics for management of upper respiratory tract infection (URTI)/pharyngitis and influenza was examined using the database of 33 203 doctor-patient encounters recorded in August and September 1994 by the TREND project. This project was part of the development of a new practice assessment in therapeutics option within the RACGP Quality Assurance and Continuing Education Program. Participating GPs recorded prospectively their drug and non-drug management, including lifestyle advice, investigations and referrals, for 110 consecutive patient encounters of all types (including surgery and telephone consultations, home, hospital and nursing home visits). The GP sample was drawn from two urban and two rural areas in NSW which were selected randomly from all NSW Divisions of General Practice, after matching within urban (16 Divisions) and rural (11 Divisions) strata. Matching variables were the index of relative socioeconomic disadvantage (from the 1991 Census5 ) and GP-to-population ratios (from the Medicare claims database as at the end of June 1993) (Gordon Calcino, Acting Director, Technical Support Section of the General Practice Branch, Department of Health and Family Services, personal communication). The rural areas included both major and outlying towns, but not remote rural areas. All GPs from the four areas were eligible for the survey, based on a list provided by the General Practice Branch from the Medicare claims database. Of the 783 GPs approached, 303 (38.7%) completed the practice assessment in 1994. Participants had a similar sex distribution to the 1994 NSW GP population, but a somewhat younger average age.6 Results Between 1990 and 1995, there was little change in the level of antibiotics dispensed through Australian community pharmacies, with an estimated 24.7 DDDs/1000 population/day dispensed in 1990 and 24.8 DDDs/1000 population/day in 1995. Pharmaceutical industry sales data of 25.2 DDDs/1000 population/day in 1989 and 24.8 DDDs/ 1000 population/day in 1994 (0.3% fall on compound annual growth rate) confirm this stability in overall use. International comparisons of antibiotic usage Retail sales of oral antibiotics in Australia and seven major developed countries in 1985, 1989 and 1994 are compared in Figure 1. Like most developed countries, Australia had a high use of oral antibiotics. In 1994 retail sales in Australia were second to those in France and followed closely by those in the United States. However, between 1989 and 1994 sales in Australia did not show the compound annual growth seen in all the other countries except Canada -- France (up 2.8%), United States (up 2.3%), Italy (up 2.9%), West Germany (up 4.4%) and the United Kingdom (up 3%). Sales of oral antibiotics to hospitals in 1994 and the percentage this represented of the total market are shown in Box 1 (above). The percentage was similar in Australia, Canada and the UK (7%, 9% and 11%, respectively), lowest in the US (5%) and highest in West Germany (38%). Figure 2 shows the percentage split of the oral antibiotic market by drug class in 1994. Australia had the highest percentage use of tetracyclines (25.5% of total oral antibiotics), but the lowest use of fluoroquinolones (2.2%) and mid range use of penicillins -- both narrow spectrum (7.1%) and broad spectrum (35%). The overall profile of antibiotic use in Australia was similar to that in the UK. Types of antibiotics used in Australia and indications The top 10 antibiotics, on prescription volume, dispensed through Australian community pharmacies in 1990 and 1995 are shown in Box 2. Amoxycillin was the most-dispensed antibiotic in 1990 and, although declining in use, remained in this position in 1995. Dispensing of doxycycline and erythro mycin also declined, while that of amoxycillin-clavulanate increased. Cefaclor and roxithromycin were new additions to the top 10 dispensed antibiotics in 1995. Converting prescription volume to DDDs/1000 population/day altered the relative ranking of some drugs. For example, drugs in the tetracycline group, which have increased maximum quantities available for treatment of severe acne, rose in rank (1990). In contrast, cefaclor, which has a high DDD (1.5g) by Australian standards, fell from third to seventh position (1995). Box 2 also shows antibiotic prescribing profiles for various indications in 1995. For sinusitis, the most prescribed antibiotics were doxycycline (20.7%), amoxycillin-clavulanate (18.1%) and cefaclor (15.1%). For bronchitis, the most prescribed antibiotic was amoxycillin (18.1%), followed closely by roxithromycin (16.5%) and cefaclor (15.2%). In urinary tract infections, trimethoprim-sulfamethoxazole (28.5%) was most commonly prescribed, followed by cephalexin (18.9%) and amoxycillin-clavulanate (17.2%). Antibiotic prescribing for upper respiratory tract infection (URTI)/pharyngitis and influenza was examined in the TREND sample of GPs from the August-September 1994 audit; 11.6% of encounters were for URTI/pharyn gitis and 1.2% for influenza. For new cases of URTI/pharyngitis, an antibiotic prescription was recorded for 57% of urban patient encounters and for 73% of rural patient encounters. Corresponding figures for antibiotic prescribing in new cases of influenza without pneumonia were 30% of urban and 62% of rural patient encounters. The TREND project did not evaluate whether the prescription was to be filled only under certain conditions (e.g., if symptoms had not improved after a certain interval), but some GPs commented that this was their advice to patients. For symptomatic management, the most common choices were decongestants and analgesics. AMI survey data showed that overall antibiotic usage by age broadly followed the proportional representation of particular age groups in the community, with the exception of the 0-19 years age group. This group received 36.9% of antibiotic prescriptions, but made up only 28.7% of the population. However, for specific conditions the age patterns varied. For example, the TREND project showed that an antibiotic was less often prescribed for children aged 0-5 years with URTI (34.1%) than for adults aged 50 years and over (62.5%). Figure 3 shows quarterly fluctuations in dispensing of oral antibiotics compared with oral β-blockers -- a drug type used on an ongoing basis. Antibiotic dispensing was markedly seasonal, with higher levels in the winter quarters (April to June and July to September), while dispensing of oral β-blockers was low at the beginning of the year and high at the end. The second pattern was typical of "safety net" fluctuations.7 These result from Pharmaceutical Benefits Scheme (PBS) provisions that provide drugs free, or at lower cost, to the patient if they are dispensed after the patient has incurred a set expenditure on PBS items in a calendar year (the "safety net" threshold). Consequently, patients tend to fill repeat prescriptions towards the end of the safety net year, after they reach this threshold. Changes to reduce these fluctuations were introduced in November 1994. Discussion This report is a unique attempt by diverse groups to combine their data sources to give a more complete picture of antibiotic use in Australia than has previously been available. The comparison between seven major developed countries showed that community use of antibiotics in Australia between 1985 and 1994 was high -- second only to France, with the US a close third -- but did not increase during the 1990s, as it did in most of the other countries. In 1994, hospitals accounted for only 7% of retail sales of oral antibiotics in Australia, similar to the percentages seen in Canada and the UK. Similarly, a survey of cardiovascular drug use in Australian public hospitals found that hospital use accounted for less than 10% of the total use of all cardiovascular drug groups.8 The highest percentage of antibiotic use in the hospital sector was found in West Germany, where capping of GP prescribing budgets was introduced in 1993. It has been argued that these prescribing budgets for reimbursable drugs have increased hospital budgets.9 Australia had the highest percentage use of tetracyclines among the seven major developed countries, possibly because of its use in managing acne. In contrast, Australia had the lowest percentage use of fluoroquinolones, most likely because of PBS prescribing restrictions ("authority required"). Amoxycillin remains the antibiotic most dispensed through community pharmacies in Australia, but its use declined between 1990 and 1995, undoubtedly because of transfer prescribing to amoxycillin-clavulanate or other antibiotics. Concerns over an increased risk of severe adverse reactions with trimethoprim-sulfamethoxazole in the elderly10 and of hepatotoxicity with flucloxacillin11 were probably respon sible for the marked fall in use of these drugs and the rise in use of cephalexin, a substitute for flucloxacillin in skin and soft-tissue infections pending the availability of dicloxacillin (PBS listed in 1997).12 The winter increase in dispensing of oral antibiotics in Australia contrasted with the "safety net" fluctuations of the oral β-blockers, which are used on an ongoing basis, and probably reflected treatment of respiratory tract infections. In fact, antibiotics were prescribed for 57%-73% of new cases of URTI. This contrasts with peer consensus recommendations on the use of antimicrobial drugs in medical practice. The Antibiotic guidelines13 state that for URTI "the cause is almost invariably viral" and "antibiotics are not indicated". Furthermore, TREND data show that rural GPs are more likely to prescribe antibiotics for URTI than urban GPs. The difference may reflect rural GPs' concern for the greater patient travel and inconvenience in visiting the doctor in the country, with prescriptions being supplied for use if symptoms fail to resolve after a period of time. However, it may also reflect differences in access to continuing education and in industry promotion between rural and urban GPs. The data also provide insight into GPs' perceptions of antibiotic resistance among bacteria. For sinusitis, the most prescribed antibiotics were doxycycline, amoxycillin-clavulanate and cefaclor, which are recommended if resistance to amoxycillin issuspected or proven.13 For bronchitis, amoxycillin was most prescribed, followed closely by roxithro mycin and cefaclor, which are recommended if a b -lactamase producing organism is isolated or if the clinical response is slow. Our results indicate a strong perception among doctors that resistant organisms are a significant clinical problem, at least for sinusitis and bronchitis. Reasons for this are unclear and deserve investigation; they may include previous clinical experience of slow resolution of these infections with standard therapy, or awareness of the prevalence of resistant bacteria in the local community. A corollary to the study of antibiotic use is an examination of the patterns of antibiotic resistance in bacteria, which may be associated with levels of use of particular antibiotics and with total use. This issue is currently being explored in Australia by the Australian Group on Antimicrobial Resistance and by the National Antimicrobial Resistance Surveillance Program and internationally by the Alexander Project. Acknowledgement Members of the Antibiotic Working Group, which helped prepare these data were: Drug Utilization Sub-Committee: Julie Lindner, Peter McManus, John Marley, Andrew Parkes and John Primrose. Australian Pharmaceutical Manufacturers Association and pharmaceutical industry: Lee Ausburn, Roger Fraser, Steven Fairall, Mendel Grobler, Leigh Hammond, Peter Kofler and Jenny Winter. Royal Australian College of General Practitioners Therapeutics Resource and Educational Network for Doctors (TREND): Andrea Mant and Sue Whicker. The TREND project was funded by a grant from the Pharmaceutical Education Program of the Department of Health and Family Services. References Birkett DJ, Mitchell AS, Godeck A, et al. Profiles of antibacterial drug use in Australia and trends from 1987 to 1989. A report from the Drug Utilization Subcommittee of the Pharmaceutical Benefits Advisory Committee. Med J Aust 1991; 155: 410-415. Edmonds DJ, Dumbrell DM, Primrose JG, et al. Development of an Australian drug utilisation database. A report from the Drug Utilization Subcommittee of the Pharmaceutical Benefits Advisory Committee. PharmacoEconomics 1993; 3: 427-432. Nordic Council on Medicines. Nordic Statistics on Medicines 1990-1992. NLN publication number 34. Uppsala, Sweden: NLN, 1993. Hurley SF, McNeil JJ, Berbatis CG. Sources of Australian pharmacoepidemiology data. Community Health Studies 1988; 12: 82-96. Australian Bureau of Statistics. Index of relative socioeconomic disadvantage. Canberra: ABS, 1993. (Catalogue no 1356.0.) Australian Institute of Health and Welfare. Medical labour force 1992-93. National Health Labour Force Bulletin No. 3. Canberra: Australian Institute of Health and Welfare, Jul 1995. McManus P. Drug utilisation [letter]. Med J Aust 1993; 158: 724. Doecke C, Harvey R, Havas L. Cardiovascular drug use in Australian hospitals 1990. Summary report of a survey conducted by the Society of Hospital Pharmacists of Australia and the Australian Institute of Health for the Commonwealth Department of Community Services and Health. Canberra: the Department, Oct 1991. German drug caps boost hospital costs SCRIP 1993; 1877: 4. Adverse Drug Reactions Advisory Committee. Trimethoprim-sulphamethoxazole warning on elderly. Aust Adverse Drug React Bull 1990 Fed. Fairley CK, McNeil JJ, Desmond P, et al. Risk factors for development of flucloxacillin associated jaundice. BMJ 1993; 306: 233-235. Turnidge J. What to use instead of flucloxacillin [editorial]. Aust Prescriber 1995; 18: 54-55. Victorian Medical Postgraduate Foundation. Antibiotic guidelines 1996/97. 9th edition. Melbourne: The Foundation, 1996. (Received 19 Dec 1996, accepted 29 Apr 1997) Authors' details Department of Health and Family Services, Canberra, ACT. Peter McManus, BPharm, MMedSc, Secretariat, Drug Utilization Sub-Committee; John G Primrose, FRACR, Medical Advisor, Health Benefits Division. SmithKline Beecham (Aust), Melbourne, VIC. M Leigh Hammond, FRCPA, Medical Director. Therapeutics Unit, Royal Australian College of General Practitioners, Sydney, NSW. Susan D Whicker, PhD, Scientific Director. Drug and Alcohol Program, Eastern Sydney Area Health Service, Sydney, NSW. Andrea Mant, MD, FRACGP, Clinical Director. GPS Business Unit, Eli Lilly, Sydney, NSW. Steven R Fairall, BScAg, Associate Director. Reprints will not be available from the authors. Correspondence: Mr P McManus, Drug Utilization Sub-Committee, Department of Health and Family Services, GPO Box 9848, Canberra, ACT 2601. E-mail: peter.mcmanus @ health.gov.au Make a comment - - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia. We appreciate your comments.

Peter McManus · John G Primrose · Andrea Mant · Steven R Fairall

The public health impact of dog attacks in a major Australian city Peter G Thompson Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Abstract - Introduction - Methods - Results - Discussion - References - Authors' details - ©MJA1997 Abstract Objective: To examine the impact of dog attacks by determining the incidence and risk factors for dog attacks. Design: Injury surveillance data on dog attacks for a major metropolitan hospital were converted to incidence rates using 1991 census figures for the hospital catchment area and combined with data on community attitudes and experiences derived from a large community survey. Setting: Queen Elizabeth Hospital (tertiary referral hospital), Adelaide, South Australia, January 1990 to July 1993. Participants: 356 victims of dog attacks who presented to the emergency department and 3093 respondents to the 1992 South Australian Health Omnibus Survey. Main outcome measures: Rates of dog attack by age and sex of the victim, hospital presentation and admission; differences in the representation of various dog breeds in attacks. Results: About 6500 people are injured in Adelaide each year as a result of dog attacks and about 810 seek hospital treatment (7.3 per 10 000 people per year). Children aged 0-4 years were attacked and required hospital treatment twice as often as adults aged 21-59 years, and men aged over 76 years twice as often as men aged 36-75 years. Males were more at risk of attack than females for all age groups. Hospital admission rates were five times higher for the elderly (95% confidence interval [CI], 2.3%-10.2%) and seven times higher for children 12 years and under (95% CI, 3.4%-15.1%) compared with people aged 13-59 years; 90% of children were admitted because of head and facial bites. The risk of attack from german shepherds, bull terriers, blue/red heelers, dobermans and rottweilers was four to five times higher than for other common breeds. Conclusions: The public health implications of dog attacks are significant and there needs to be increased awareness of the risks to young children. Potential interventions to reduce the incidence of dog attacks vary from strict controls on high-risk breeds to mandatory leashing to a "user pays" liability insurance proposal. MJA 1997; 167: 129-132 Introduction Dog attacks are a major cause of human injury in Australia. In 1991, it was estimated that there could be up to 30 000 people presenting to hospital annually as the result of dog attacks in Australia.1 Injury records from the Women's and Children's Hospital in South Australia show that dog attacks are the fourth most common reason for children being taken to hospital, after accidents from playground equipment, bicycles and motor vehicles.2 Studies from other States3,4 also report a high level of childhood injuries related to dog attacks, and a recent South Australian report5 confirmed that dogs were a significant cause of injury at all ages, including the elderly. In the United States, there has been a 37% increase since 1986 in dog bites that required medical attention, and dog attacks eclipse measles, mumps and whooping cough combined as a health threat to American children.6 To determine the impact of dog attacks and identify possible interventions to reduce their frequency, we examined surveillance data from a major metropolitan hospital in Adelaide and data from a large community survey. We report the rates of hospital treatment and admission for dog attacks, the severity of injuries, the groups most at risk of attack, community concern about dog attacks and a comparison of the relative risk between dog breeds. Methods Two data sources were used in this study: the South Australian Health Commission's Injury Surveillance System, and the 1992 South Australian Health Omnibus Survey. In both data sources, a "dog attack" was defined as an intentional bite by the dog, or direct aggression causing injury to the victim. 1991 Census population statistics were also used to determine the age- and sex-specific rates of dog attack, as well as the age-specific rates of admission to hospital resulting from dog attacks. Ethics approval was provided by the University of Adelaide. Injury Surveillance System The South Australian Health Commission's Injury Surveillance System automatically receives information from victims who present to selected metropolitan public hospitals for treatment. For the purposes of this study, it provided information about all victims of dog attacks (e.g., age and sex of victim, type of injury, location and description of incident and treatment) who presented to Queen Elizabeth Hospital in Adelaide between January 1990 and July 1993. This system, which includes all age groups, has the advantage of documenting the information at the time of treatment (in the hospital), which reduces the possibility of subsequent recall bias. Queen Elizabeth Hospital was chosen for this study because it has a well-defined catchment area with natural geographic boundaries on two sides. The other boundaries were determined by selecting the midpoint between adjacent public hospitals. Approximately 13% of the victims of dog attacks in the Adelaide metropolitan area who required hospital treatment between January 1990 and July 1993 presented to Queen Elizabeth Hospital. From a total of 356 attacks, the mean number by age and sex per year was calculated. The Injury Surveillance System provided the breed of dog (when it was known). We were confident that the breed names were accurate because in at least half of the attacks the victim was the dog's owner, a family member or a person who knew the dog well and the breeds named were common and easily recognised. Breeds that were unknown could have been a source of bias if their breed distribution was different. However, a comparison of victims who named the dog breed with those who did not failed to show any appreciable differences with regard to age, sex, dog ownership, body part injured and injury severity. The breed distribution of known breeds also largely agreed with other investigations.4,7-10 An indicator of the health impact of the injury on the person's life was whether the victim was admitted to hospital after initial examination in the emergency department. Those who were admitted were expressed as a proportion of the total number of people presenting to the emergency department. As data for all admissions came from the same hospital, the selection criteria for admission were likely to be consistent. The distribution of injury by body part was also examined. Health Omnibus Survey The 1992 South Australian Health Omnibus Survey11 contains information obtained from interviews with 3093 randomly selected persons in Adelaide in 1992.11 The annual Omnibus Survey is a population health survey that provides a large representative sample of the attitudes towards health issues and experiences of people aged over 15 years. For our investigation, 13 questions concerning dog attacks were incorporated into the Omnibus Survey, including: Does anyone in this household own a dog? What is the breed of the dog? Have you been attacked by a dog in the past three years? Whose dog was it? Where did the attack occur? To what extent do you fear being attacked or threatened by a dog? Respondents were also asked about injuries sustained and treatment received. Therefore, the Omnibus Survey provided data not only about victims of dog attacks who presented to hospital, but also data on victims of dog attacks who may have consulted a general practitioner as well as those who may not have been injured at all. The Omnibus Survey also provided information on the distribution of the dog population by breed. The frequency of breeds involved in attacks was converted to a representation ratio to compare the relative risks between breeds. The ratio was calculated by dividing the percentage of attacks per breed by the percentage of the total dog population represented by the same breed. Representation ratios allow confirmation of whether certain breeds of dog attack more frequently because they are more commonly chosen as pets (e.g., german shepherds may cause 25% of all attacks simply because they comprise 25% of the dog population). Population statistics from the Omnibus Survey as well as the 1991 Census were used to examine the demographics of the catchment area of Queen Elizabeth Hospital in comparison with metropolitan Adelaide. From an examination of the data on age, ethnicity and socioeconomic status, it was concluded that the catchment was representative of metropolitan Adelaide. Statistical analysis Ninety-five per cent confidence intervals [CIs] for admission rates were attributed to Lilienfeld and Lilienfeld,12 and 95% CIs for admission rate relative risks attributed to Rothman's analysis of crude data.13 Results Frequency of dog attacks: presentation to hospital Box 1 shows the age- and sex-specific rates of dog attack calculated from victims who presented to the emergency department of Queen Elizabeth Hospital from January 1990 to July 1993. The 356 dog attacks for this period equate to 7.3 attacks per 10 000 people per year requiring hospital treatment. The rate of dog attack for men over the age of 76 was nearly double the rate for men aged 36 to 75, but this was not statistically significant, possibly because of the small sample size of older men. Notably, the rate for children aged 0 to 4 years was twice that for adults aged 21 to 59 years. This rate was likely to be conservative because some children in the catchment area of Queen Elizabeth Hospital may have been taken directly to the Adelaide Children's Hospital. There was also a marked difference between the rates for men and women. Men had, on average, a 50% higher risk of attack at all ages ( Figure 1). Frequency of dog attacks: community survey Of the 3093 respondents to the Omnibus Survey, one in 20 reported that they had been attacked by a dog at least once in the past three years, and a third had been attacked more than once in the past three years. More than half (51%) reported that they had been attacked in a street or public place. Of the 88 people who reported in the Omnibus Survey that they had been injured by dogs and had required treatment, 35 people (40%) had consulted a doctor and 11 people (12.5%) had sought hospital treatment per year. The Omnibus Survey reported that 37.2% of households in metropolitan Adelaide owned at least one dog. The 1992 Dog Control Review Report estimated that there were about 190 000 dogs in metropolitan Adelaide.14 Admission to hospital Box 2 (above) shows the number of victims of dog attacks who were admitted to Queen Elizabeth Hospital between January 1990 and July 1993. The rates of admission to hospital, as an indicator of the health impact of dog attack, were five times higher for elderly people (95% CI, 2.3-10.2) and seven times higher for children (95% CI, 3.4-15.1) than for people aged 13-59 years. Nearly two-thirds (66%) of children aged up to 12 years received head and facial bites ( Figure 2); these injuries were responsible for 90% of admissions in this age group ( Figure 3). Relative risk of dog attack, by breed Box 3 (below) shows the proportion of dog attacks by various breeds, the representation of particular breeds in the total dog population, and the relative risk of attack by those breeds (representation ratio). The Injury Surveillance System provided the breed of dog in 43% of attacks (154). It can be seen that the first five breeds were responsible for 73% of all hospital-treated attacks, yet they represented only 31% of the dog population. The relative risk of attack by a german shepherd was about five times greater than a collie (2.5/0.5 = 5). Bull terriers, red/blue heelers and rottweilers presented a four-times-higher risk. The relative risk of attack by a doberman was even higher. It is possible that more dangerous dogs existed (e.g., the prohibited American pit bull terrier), but they did not feature in the Injury Surveillance System data because they comprised a small proportion of the dog population. Fear of dog attacks Half of the respondents to the Omnibus Survey felt threatened or feared being attacked by dogs (95% CI, 48.4%- 51.9%). Of those who were afraid, 28.4% said their concern was minor in that it did not affect their behaviour, 18.7% felt moderate concern which had had an effect on their behaviour (such as planning safer routes away from known dogs), and the remaining 3.1% expressed major concern which had had more dire consequences (such as deciding not to leave the house to go shopping). Incidence of dog attacks The total number of attacks represented a rate of 2.85% per year, which corresponds to about 29 000 attacks in metropolitan Adelaide each year, based on the 1991 Census population of 1 023 278. The total number of people injured and requiring treatment represented a rate of 0.63% per year, which corresponds to about 6500 people being injured and requiring treatment following dog attacks in Adelaide each year, with 2600 persons consulting a doctor and 810 seeking treatment at a hospital. If the overall rate of presentation to Queen Elizabeth Hospital following a dog attack (i.e., 7.3 per 10 000 people per year) is applied to the population of Adelaide, it corresponds to 750 persons presenting to hospital each year. This figure is close to the rate of 810 reported in the Omnibus Survey. If Adelaide is considered similar to most other Australian metropolitan areas, it could be expected that around 100 000 Australians will be injured and require treatment each year as a result of dog attack and that about 13 000 will seek treatment at a hospital. Discussion In this study, three-quarters of all hospital-treated dog attacks were caused by just five of the 160 or so available breeds. Limiting the availability of these breeds would be one way of reducing injury. Alternatively, ownership could be restricted to certified owners who accept responsibility to place specific controls on these breeds. These controls include obedience training and dog behaviour assessment, ensuring that the dog is on a leash at all times in public, the home property is securely fenced and warning signs have been erected for visitors. Owners should also be encouraged to join dog clubs to raise awareness of the responsibilities involved in owning a dog. More than half the attacks reported in this study occurred in a street or public place by loose uncontrolled dogs. It is reasonable to assume that if the dogs had been restrained these attacks would not have occurred. The Australian Capital Territory, the Brisbane City Council, and a number of Victorian councils have adopted the strategy of requiring all dogs to be on a leash at all times in public. Councils in those States that still consider dogs need only be under the verbal control of their master in public places should consider this safer option. Brisbane City Council also requires mandatory fencing to contain dogs within their owner's property. Data from the Injury Surveillance System clearly show that dogs and very young children frequently do not mix.1 Parents of young children would be wise to postpone purchase of a dog until their children are older, preferably more than five years of age. A nationwide publicity campaign is recommended to alert parents to the dangers, especially in view of the high level of attacks to the head and face of children found in this study. Another option to reduce dog attacks could be to adopt a "user pays" element into dog ownership by introducing a third party insurance scheme. The issue of a registration permit could be conditional on the presentation of a suitable insurance agreement. In 1993, a South Australian court awarded $380 000 to a garbage collector for injuries sustained when attacked by an unrestrained dog -- the dog's owners were found responsible for the damages.15 For low-risk breeds, it is anticipated that there would be no additional premium to standard home insurance cover, but for high-risk breeds an increased premium would be likely. The premium would ultimately be determined by the extent of the claims relevant to each particular breed (i.e., the performance of the insured determines the cost). The paying of an additional premium would have the effect of deterring "spur-of-the-moment" buyers by encouraging them to think more carefully when choosing a breed and perhaps buy a lower-risk breed. Another benefit would result from insurance companies insisting on better ownership practices for particular breeds (as outlined at the beginning of the Discussion) before issuing policies. The rates of dog attack in Adelaide were projected to the nation as a whole because most Australians live in metropolitan areas and large regional centres (similar to Adelaide) and it was therefore considered that dog attacks were a widespread public health problem. The finding that half of the population surveyed were concerned about being attacked by dogs indicates that strengthening of dog-control policies will be more acceptable to the community than previously thought. In view of rising community concern and increasing media reports on dog attacks, owners must take more responsibility and put in place measures to reduce the incidence of dog attacks. References South Australian Health Commission. Dog attacks. Inj Surveill Monthly Bull January 1991; 29: 1-2. Williams N. Women's and Children's Hospital. The perils of being a kid . The Advertiser (Adelaide) August 1995. Ashby K. Dog bites. Victorian Injury Surveillance System. Hazard 1996; 26: 7-13. Podberscer AL, Blackshaw JK, Nixon JN. The incidence of dog attack in children treated at a city hospital. Aust Vet J 1990; 67: 79-80. Langley A, Dantalis N, Edwards-Bert P. Environmental health in the home. Adelaide: South Australian Health Commission, 1996: 10-32. Wulf S. Man's best friend? Time 1997; June 23: 68. Greenhalgh C, Cockington R, Raftos I. An epidemiological survey of dog bites presenting to the emergency department of a children's hospital . J Paediatr Child Health 1991; 27: 171-174. Thomas PR, Buntine JA. Man's best friend? A review of the Austin Hospital's experience with dog bites. Med J Aust 1987; 147: 536-540. Langley J. The incidence of dog bites in New Zealand. Injury Prevention Research Unit, Preventive and Social Medicine. N Z Med J 1992; 105: 33-35. Avner JR, Baker MD. Dog bites in urban children. Pediatrics 1991; 88: 55-57. Harrison R. 1992 Health Omnibus Survey -- A research report. Adelaide: Harrison Market Research Pty Ltd; 1993: 11-21. Lilienfeld AM, Lilienfeld DE. Foundations of epidemiology. 2nd ed. New York: Oxford University Press, 1980: 336-337. Rothman KJ. Modern epidemiology. Boston/Toronto: Little, Brown and Company, 1986: 155-175. KJ McCann. Dog Control Review Report. Adelaide: South Australian Department of Environment and Planning, 1992. Revalk J. Dog scare garbo gets $380 000 for injuries. South Australian Advertiser March 1993. (Received 20 Aug 1996; accepted 26 May 1997) Authors' details Injury Surveillance and Control Unit, South Australian Health Commission, Adelaide, SA. Peter G Thompson, MPH, Injury Epidemiologist. Reprints will not be available from the author. Correspondence: Mr P G Thompson, Public and Environmental Health Service, South Australian Health Commission, PO Box 6, Rundle Mall, SA 5000. E-mail: somers.ronald@health.sa.gov.au ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Peter G Thompson

A model for the management of self-poisoning Ian M Whyte, Andrew H Dawson, Nicholas A Buckley, Gregory L Carter and Catherine M Levey Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Abstract - Introduction - Service structure - Philosophy and strategies - Nursing perspective - Psychiatric perspective - Medical perspective - Outcomes and resource use - Discussion - Acknowledgements - References - Authors' details - ©MJA1997 Abstract Objective: To describe the development and activity of a multidisciplinary service to manage self-poisoning. Design: Descriptive, comparative study with prospective data collection. Setting: Regional toxicology treatment centre in the Hunter area of New South Wales (NSW) with primary and secondary referral service to 385 000 people and tertiary referral service to a further 100 000. Patients: All patients (1987-1995) with poisoning or envenomation presenting to the Hunter Area Toxicology Service (HATS). Main outcome measures: Average length of stay for HATS compared with national and NSW hospitals; mortality data for HATS compared with NSW. Results: Average length of stay for HATS was 0.53-1.22 days shorter than for all Australian hospitals, potentially saving 518 bed-days, valued at $468 000 per year. Average length of stay was 0.94-3.39 days shorter than for all NSW hospitals, saving 1470 bed-days at $1.4 million per year. Inpatient mortality (0.2%; 95% confidence interval, 0.0-1.1) was not significantly different from NSW (0.5%; 95% CI, 0.2-0.8). Standardised mortality ratios showed no greater all-cause suicide mortality. Conclusions: In our centralised model for managing self-poisoning, all toxicology patients in an area health service are diverted to one hospital, where all patients with deliberate self-poisoning are admitted under the one multidisciplinary team, and all receive psychiatric assessment. This model has substantially reduced bed stay, with considerable savings to the Hunter Area Health Service manifested as an increase in beds available for other purposes. MJA 1997; 167: 142-146 Introduction Estimates of admissions for deliberate self-poisoning vary from 1%1 up to 5%2 of public hospital admissions. More than 50% of these admissions occur between 6 pm and 2 am.3 Deliberate self-poisoning (including carbon monoxide) is the cause of death in 42% of suicides.4 With a few exceptions, deliberate self-poisoning is managed on an ad-hoc basis in Australian hospitals. Commonly, the patient is managed in the emergency department and, if required, admission occurs under the general physician of the day or under the specialty which best corresponds to the patient's toxicological problem. Other models include medical management for most patients occurring entirely within the emergency department/intensive care axis. In one centre, 30% of patients with deliberate self-poisoning were not formally admitted.5 In many centres, expertise in toxicology comes from outside the service providing the patient care (e.g., from Poisons Information Centres). In these models of management, not every patient with deliberate self-poisoning receives formal psychiatric assessment. Despite evidence that psychiatric intervention after parasuicide is worthwhile,6 psychiatric resources are commonly concentrated on those patients who require admission and those who have the most medically severe poisoning.7 However, significant suicidal risk is present for many patients with toxicologically "trivial" poisonings. Service structure In 1986 the Department of Clinical Pharmacology, then located at the Royal Newcastle Hospital, was requested to manage deliberate self-poisoning and other toxicology patients. The Hunter Area Toxicology Service (HATS) was established jointly by the Department of Clinical Toxicology and Pharmacology and the Department of Liaison Psychiatry in January 1987. The only increase in staff was one registrar position in clinical pharmacology. All deliberate self-poisoning patients are formally admitted under the HATS clinical toxicologist, who retains primary responsibility for care during the whole admission. A toxicology data collection form was developed which is also the formal admission record. The psychiatry team assess all patients with deliberate self-poisoning and, on request, other poisonings. Referral to the drug and alcohol service occurs as necessary. The patient is determined as medically fit for discharge by the toxicologist and the decision on appropriate discharge destination is made by the psychiatrist. Medical follow-up, when required, is the responsibility of the toxicologist. A relational database for collecting data on poisoned patients4 was written (by I M W) in late 1986. The complexity of this database has progressively increased and an extensive psychiatric component (written by G L C) became operational in January 1996. HATS was transferred to the Newcastle Mater Misericordiae Hospital in 1991 and took on an Area role (population, 385 000). All poisoning cases are transferred, either directly or after assessment at a closer hospital, to the Newcastle Mater Misericordiae Hospital unless they are too ill. If they are admitted to another hospital, they are admitted under the care of HATS. In practice, this relates to critically ill patients who are admitted to the intensive care unit at the presenting hospital under the care of the toxicologist from HATS, and discharged directly from that unit or transferred to the Newcastle Mater Misericordiae Hospital if they need more inpatient care after their intensive care stay. HATS provides a 24-hour telephone consulting service for the Upper and Lower Hunter Areas (population, 100 000) and a tertiary referral service when required. The clinical pathway for this managed care is shown in Figure 1. HATS 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. If 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. Philosophy and strategies HATS was established with the premise that deliberate self-poisoning is a presenting symptom for an underlying psychiatric disorder, personality disorder or psychosocial problem that requires assessment and intervention. A distinction is made between "drug overdose" (exposure to an amount of drug or toxin sufficient to cause harm) and the more inclusive term "deliberate self-poisoning", which also includes toxicologically trivial exposures. All admissions are formally discussed at a weekly multidisciplinary meeting where medical and psychiatric management is reviewed. When appropriate, individualised management plans are discussed for patients who have frequent presentations. Nursing perspective Nursing care of deliberate self-poisoning patients uses a combined medical and behavioural model. The staff recognise that patients with deliberate self-poisoning are entitled to a legitimate "sick role"8 and use a non-judgemental approach to patients and their relatives. Retention of patients for the full duration of treatment can be increased by emphasising the need for medical review and treating deliberate self-poisoning patients in a similar manner to other medical patients. In the acute phase of the admission, patients are kept in hospital pyjamas and their street clothes removed. Patients with catheters or intravenous cannulas often have these devices kept in situ until their mental state is assessed and their discharge destination is determined by the psychiatric team. The involvement of family and friends in helping to orientate and support the patient can lessen the nursing burden and improve compliance. Psychiatric perspective Psychiatric care of deliberate self-poisoning patients is aimed at maintaining the safety of the patient (and staff), enhancing compliance with decontamination and other medical treatment, psychological support, the initiation of treatment for specific indications (e.g., delirium, psychosis and relationship problems), and coordination of psychiatric follow-up. The incorporation of a psychiatry team in HATS allows for very early intervention in deliberate self-poisoning, in contrast to consulting the psychiatrist after completion of medical management. Medical perspective The primary aim in the treatment of poisoned patients is to reduce mortality and early and late morbidity. The secondary aim of treatment is to reduce hospital stay and use hospital resources efficiently. This is accomplished by an active education program9 focused on evidence-based management, good supportive care and actively discouraging punitive medical procedures. Outcomes and resource use The NSW Health Department Inpatient Statistics Collection uses average length of stay (with a minimum bed stay for a formal admission defined as one day). Examination of medical records data for patients with self-poisoning (ICD-9-CM10 codes E950-E959) admitted to the Royal Newcastle Hospital in 1985 and 1986 showed an average length of stay of 3.88 days. For 1987, when HATS began to operate, the average length of stay for this group of patients had decreased to 2.75 days and for 1988 to 1.4 days. In 1995 there were 736 admissions to HATS (see Box 1). The median (range) hospital stay is calculated because the data are not normally distributed. The lower quartile is at 10.5 hours and the upper quartile at 27.5 hours. The distribution of hospital stay for deliberate self-poisoning patients is shown in Figure 2. In 1994-1995, for all hospitals with an emergency department in the Greater Newcastle area, deliberate self-poisoning comprised 1.2% of medical admissions; most presented to Newcastle Mater Misericordiae Hospital, where they comprised 7.3% of medical admissions. Of the 520 deliberate self-poisoning admissions who received formal psychiatric assessment, 492 (94.6%) had had one or more formal diagnoses11 made of psychiatric disorder, personality disorder or other condition ("V" codes11). Average length of stay data for HATS compared with national data and all NSW public hospitals are shown in Boxes 2 and 3, respectively. Box 2 compares data derived from the HATS database for 1991-1994 with national data for 1992 (the most recent year available). Box 3 presents data from the NSW Health Department Inpatient Statistics Collection (1994-1995), and compares deliberate self-poisoning admissions to Newcastle Mater Misericordiae Hospital with the mean for all public hospitals in NSW. The data from Newcastle Mater Misericordiae Hospital in Box 3 are not derived from the HATS database, but rather from independent coding by the Medical Records Department of the Newcastle Mater Misericordiae Hospital according to ICD-9-CM.10 Both comparisons show a substantial reduction in bed stay for HATS. Since those patients not formally admitted at other hospitals are likely to be short stay presentations and thus not reported in the Inpatient Statistics Collection, we further analysed HATS data for 1993-1995. For all admissions average length of stay was 1.5 days; for all admissions with a hospital stay greater than 12 hours (72.6% of admissions) average length of stay was 1.69 days; for all admissions that required intensive care admission (16.8%), average length of stay was 2.59 days. There has been no evidence that reduced bed stay has compromised patient care, as mortality from deliberate self-poisoning during this period (1987-1995) has been 0.6% (24 deaths in 3856 deliberate self-poisoning admissions; 95% CI, 0.4-0.9). Most of these patients had an out-of-hospital cardiac arrest and death was inevitable on presentation.4 NSW Health Department data for 1992 (the most recent year for which death data are available) show 13 inpatient deaths in 2876 admissions in NSW (0.5%; 95% CI, 0.2-0.8). HATS data for 1992 show one inpatient death in 512 deliberate self-poisoning admissions (0.2%; 95% CI, 0.0-1.1). These proportions are not significantly different (chi-squared = 2.04; P = 0.36). Standardised mortality ratios for suicide in NSW show the Hunter Area has no greater all-cause suicide mortality.13 HATS' prospective data collection on all presentations in a defined population is a very powerful tool for observational research. We have been able to identify public health issues related to patterns of drug use,14,15 relative toxicity of drugs within classes16-18 and the impact of safety packaging of medications.19 The NSW Health Department, as part of its health outcomes strategy, has provided funds to HATS to develop the management model (and the database) so that it can be trialled at other centres in NSW. Discussion There are difficulties in comparing data collected by clinicians with a particular interest in a group of patients and national data derived from ICD-9 coding from all hospitals in Australia. The main difficulty is the potential for ascertainment bias. For example, it is possible the national data contain significant numbers of patients without true deliberate self-poisoning, who have a longer length of stay. This may make our comparisons less robust. However, the data for NMMH in Box 3 are the official data requested by the NSW Department of Health for inclusion in the NSW Inpatient Statistics Collection and are thus directly comparable to data from other NSW public hospitals. It could be argued that shorter length of stay in the Hunter is due to our policy of admitting all patients with deliberate self-poisoning regardless of severity. However, the greatest difference in average length of stay occurs in those patients with complications or comorbidities (Boxes 2 and 3), who require admission under any policy. Figure 2 shows that 90% of all our patients stay in hospital for less than 50 hours, which is less than the average length of stay for uncomplicated poisoning in NSW public hospitals (Box 3). In addition, HATS bed stay for all admissions (complicated and uncomplicated) after excluding those admitted for less than 12 hours (27.3% of presentations) is still shorter than the average length of stay for uncomplicated admissions to all NSW hospitals. The average length of stay for HATS admissions requiring intensive care is more than two days shorter than the average length of stay for all complicated admissions to NSW hospitals. The model of management of self-poisoning described in this article is, we believe, unique in Australia. The differences we have identified in this model are: all toxicology presentations in one Area Health Service are diverted (by ambulance services and emergency departments) to one hospital all deliberate self-poisoning presentations are admitted all admissions are to one team the team is multidisciplinary, with medical, psychiatric, drug and alcohol, and nursing participation all deliberate self-poisoning admissions receive psychiatric assessment a 24-hour service for management and advice is provided. We argue that all patients who present with deliberate self-poisoning should be admitted for several reasons: deliberate self-poisoning is a presenting symptom for another problem that requires assessment and intervention most deliberate self-poisoning admissions (94.6%) have a diagnosable psychiatric disorder, personality disorder or other psychiatric condition formal admission facilitates more efficient and effective assessment and management of both medical and psychiatric issues as more than half the presentations occur after hours, overnight admission is required to ensure adequate psychiatric assessment. This model has resulted in a substantial and significant reduction in bed stay, which increases beds available for other purposes in the Area. There are two ways of calculating the monetary cost if funding were on a diagnosis-related group (DRG) basis. The first is to multiply the bed-days saved by the DRG cost of a bed-day, as in Box 2 and Box 3. The second is to assume the saved beds will be occupied by patients attracting further DRG funding. Assigning a monetary value to this is not possible. It is clear, however, that based on DRG funding these saved bed-days are worth more to the Area than the cost of running the service. The reduction in bed stay has not been accompanied by a worsening in outcome, as defined by in-hospital mortality from deliberate self-poisoning or standardised mortality ratios for all-cause suicide. While the number of admissions to HATS in 1992 appears disproportionate, it is consistent with the proportion of admissions to other major hospitals1,2 and reflects our policy of admitting all patients who present with deliberate self-poisoning. It appears likely the Department of Health figures for admissions significantly underestimate the number of presentations for deliberate self-poisoning to NSW hospitals. If so, while the magnitude of the saving per admission may be uncertain, on a State-wide basis the potential savings from implementing our model are even greater. Without further data, determining the reasons for the shorter average length of stay is not possible, but anecdotal comparisons with other hospitals suggest the following possibilities: centralised, evidence-based management of specific poisonings resulting in earlier recognition of non-toxic or minimally toxic exposure more efficient gastrointestinal decontamination better management of significant toxic exposure more efficient use of psychiatric assessment, aftercare and discharge planning increased involvement of nursing staff in a multidisciplinary approach. Our current model of management has evolved using the skills and experience of those interested in poisoning in Newcastle. The only new position created was the registrar position in clinical pharmacology. We do not believe, however, that replicating the model or its outcomes is dependent on replicating our subspecialty mix. Nevertheless, the identification of a team to manage poisoning is crucial. In many health areas the emergency physicians may be the logical choice for such a team. This would require an extension of admitting rights into the general hospital or a collaborative venture with an identifiable medical team. A specific group of psychiatrists is also required. We believe that Area Health Services should consolidate acute toxicology services. A potential disadvantage of consolidation is loss of skills in the management of toxicological problems in other hospitals in the Area. This could be offset by making the service part of registrar and nursing training rotations. The advantages of consolidation include: individualising patient care continuity of care a better learning curve via greater experience training, education and research. The efficiencies of this model are a product of the reorganisation of largely existing resources to provide a multidisciplinary team approach to the management of poisoned patients. The provision of care is based on a philosophy that these patients are entitled to a legitimate sick role. The major stumbling block to establishing a similar dedicated service is in making the decision to reorganise existing services. As House et al. state, after reviewing services in the United Kingdom, "there is much to recommend in clinical diversity, but nothing to recommend [in] unplanned and incoordinated service provision".6 Acknowledgements We would like to acknowledge the support of nursing staff in the Intensive Care Unit, the Emergency Department and Ward 5E at the Newcastle Mater Misericordiae Hospital. The Hunter Area Toxicology Service has also received considerable support from the Mental Health Epidemiology Group (NSW Department of Health) and the Chief Executive Officer of the Hunter Area Health Service, Dr Timothy Smyth. Some of the later development of this service was supported by a NSW Health Department Health Outcomes grant and a grant from the Hunter Area Health Service. References Pond SM. Prescription for poisoning. Med J Aust 1995; 162: 174-175. McGrath J. A survey of deliberate self-poisoning. Med J Aust 1989; 150: 317-322. Buckley NA, Whyte IM, Dawson AH. There are days . . . and moons. Self-poisoning is not lunacy [letter]. Med J Aust 1993; 159: 786-789. Buckley NA, Whyte IM, Dawson AH, et al. Self-poisoning in Newcastle, 1987-1992. Med J Aust 1995; 162: 190-193. Davis AT, Kosky RJ. Attempted suicide in Adelaide and Perth: changing rates for males and females, 1971-1987. Med J Aust 1991; 154: 666-685. House A, Owens D, Storer D. Psycho-social intervention following attempted suicide: is there a case for better services? Int Rev Psychiatry 1992; 4: 15-22. Tengel E, Cook NG, Kreeger IS. Attempted suicide. London: Chapman & Hall, 1958. Parsons T. The social system. London: Routledge and Kegan Paul, 1951. Buckley NA, Dawson AH, Whyte IM. HyperTox -- a hypertext teaching program in toxicology. < http://www.ozemail.com.au/~ouad/toxi0002.html > > World Health Organisation: International Classification of Disease ICD-9. Clinical modification, 1978. Geneva: WHO, 1992. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994. Manual of resource items and their associated costs for use in submissions to the Pharmaceutical Benefits Advisory Committee involving economic analyses. Australian Government Publishing Service, Canberra, 1992. Stewart G, Chipps JA, Sayer G. Suicide mortality in NSW local government areas. NSW Public Health Bull 1995; 7: 1-10. Smith AJ, Whyte IM. New drugs for old: an issue for debate? Med J Aust 1988; 149: 581-582. Dawson AH, Whyte IM. Compound analgesics [letter]. Med J Aust 1990; 152: 334. Buckley NA, Dawson AH, Whyte IM, Henry DA. Greater toxicity in overdose of dothiepin than of other tricyclic antidepressants. Lancet 1994; 343: 159-162. Buckley NA, Dawson AH, Whyte IM, O'Connell DL. Relative toxicity of benzo diazepines in overdose. BMJ 1995; 310: 219-221. Buckley NA, Whyte IM, Dawson AH. Cardiotoxicity more common in thioridazine overdose than with other neuroleptics. J Toxicol Clin Toxicol 1995; 33: 199-204. Buckley NA, Newby DA, Dawson AH, Whyte IM. The effect of the introduction of safety packaging for carbamazepine on toxicity in overdose in adults. Pharmacoepidemiol Drug Safety 1995; 4: 351-354. (Received 26 Aug 1996, accepted 3 Apr 1997) Authors' details Newcastle Mater Misericordiae Hospital, Newcastle, NSW. Ian M Whyte, FRACP, Senior Staff Specialist and Director, Department of Clinical Toxicology and Pharmacology. Andrew H Dawson, FRCP, FRACP, Staff Specialist, Department of Clinical Toxicology and Pharmacology. Gregory L Carter, FRANZCP, Senior Staff Specialist, Department of Liaison Psychiatry. Catherine M Levey, RN, ICUCert, Clinical Nurse Specialist, Intensive Care Unit. Discipline of Clinical Pharmacology, University of Newcastle, Newcastle, NSW. Nicholas A Buckley, FRACP, Lecturer. Reprints: Dr I M Whyte, Department of Clinical Toxicology and Pharmacology, Newcastle Mater Misericordiae Hospital, Locked Bag 7, Hunter Regional Mail Centre, NSW 2310. E-mail: mdimw@cc.newcastle.edu.au ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Ian M Whyte · Andrew H Dawson · Nicholas A Buckley · Gregory L Carter · Cathterine M Levey