Poisons unit helps get patient to the right place sooner

The number of people needing hospital treatment for suspected poisoning is rising. Here, Lowri Jackson from the Royal College of Physicians explains how the Welsh Poisons Unit is transforming care and taking pressure off emergency departments

MORE than 170,000 people need hospital treatment for suspected poisoning each year in the UK.

In 2015, 3,674 people died from the effects of poisoning in the UK – the highest number since records began in 1993.

Sadly the vast majority of these patients were either trying to selfharm or commit suicide.

The Welsh National Poisons Unit is made up of the National Poisons Information Service (NPIS) in Cardiff and the Gwenwyn poisons treatment ward at University Hospital Llandough.

The NPIS is a network of four units comprising of physicians and scientists which offers advice to improve the management of poisoned patients, often avoiding unnecessary admissions.

Gwenwyn ward is a purpose-built, eight-bed unit facilitating an holistic approach to care.

It is staffed by nurses, including two ward-based psychiatric nurses, and supported by a team of clinical pharmacologists and toxicologists.

Dr John Thompson, a consultant clinical pharmacologist based on the Gwenwyn poisons treatment ward, said: “The relationship is very close between physicians and psychiatry on this ward.

“Virtually all of the psychiatric reviews are carried out by our two specialist psychiatric liaison nurses during the week.

“If they’re not there, we can use the on-call psychiatry service. We aim to do a psych review on every patient that’s admitted onto the poisons ward.”

These reviews are often very sensitive, particularly in the case of selfharm.

“During a ward round I would have to ask some difficult questions of these patients – why did you do it? Do you still want to kill yourself?

“Compared to other places where I’ve worked, I now don’t have to do that in a rushed environment on an open ward behind the magic soundproof curtain.

“We can have interviews in private, behind closed doors, carried out by specialty psychiatric liaison nurses.”

There is also a deliberate self-harm working group made up of psychiatric liaison nurses, clinical pharmacologists, A&E consultants, psychiatrists and other professionals.

“We used to try and put together individual management plans for repeat attenders.

“But, medically, that’s not always needed – often the psychiatric care is the main thing, and that plan can be shared between us, A&E and the patient’s GP, so everyone’s in the loop.”

This multi-disciplinary team has developed close links with social care and community teams.

Once a patient has been through a psychiatric review, they may be referred to a crisis team, discharged into the community with a follow-up plan or admitted into a psychiatric unit.

“Our psychiatric nurses work very closely with social care. If someone is homeless, we don’t just discharge them.

“Sometimes that can be easy, sometimes that can be very difficult, especially if a patient has been abusing drugs or alcohol.”

Given the complex lives of many of these patients, it’s also vital that the unit has a good working relationship with the police and social services.

Dr Thompson argues that this is another reason why the team is so important.

“We’re very clear that we’re a hospital – we’re not a custody suite.

“If a patient is medically fit to be discharged, we cannot stop them from leaving. Often the police don’t want these patients in custody in case something goes wrong, but because we encounter these situations regularly and we talk to our senior managers – who are incredibly supportive and very effective – and we take legal advice, it means that we know what to do the next time it happens.”

The Royal College of Psychiatrists in Wales says that until recently, liaison psychiatry services were woefully underfunded in the UK, but even more so in Wales.

In 2014, the NHS Wales Delivery Unit found that provision was at best patchy and at worst not available or not adequate.

The Welsh Government has since promised that psychiatric liaison teams will be set up at all district general hospitals, although these services are still at different stages of implementation.

More than 80% of the 1,200 to 1,800 patients requiring admission in Cardiff are admitted directly, avoiding more than 1,000 unnecessary emergency department attendances every year.

“We met with the Welsh Ambulance Service and together developed an agreement – if patients match certain criteria, they come straight here, bypassing A&E.”

The unit has also seen a fall in average length of stay from 34 to 18 hours, so, despite increased demand, no extra beds have been needed.

“We’re now getting the patient to the right place much, much sooner.

“It’s just a much more efficient way of doing things.”

So what lessons could colleagues working in general medicine and other specialties learn from the experience of the Welsh Poisons Unit?

Dr Thompson added: “We could certainly do with more liaison psychiatry access for our general medical inpatients.

“The poisons unit has several big advantages: one is that our nurses are highly-trained specialists.

“They’re very non-judgemental and they know how to communicate with agitated or challenging patients.

“Having these patients on my general medical ward, mixing with very frail, older patients with dementia – it would be an absolute nightmare, a very unhappy mix.

“It’s also a risk-assessed environment with alarms, CCTV, safety features and, of course, a private room to take a psychiatric history properly without interruptions.”

The Welsh Poisons Unit also hosts NPIS (Cardiff ), a multidisciplinary team consisting of 10 poisons information scientists who provide telephone advice to the NHS.

It is supported by four consultant clinical pharmacologists and toxicologists and two specialist clinical pharmacology registrars.

Staff at NPIS (Cardiff) also contribute to the TOXBASE database, which contains more than 17,000 product entries.

This is the first-line toxicology online advice service to the NHS.

Last year there were 608,868 TOXBASE user sessions and 1.69 million separate page views of TOXBASE entries.

NPIS (Cardiff ) also leads on the UK Poisons Information Database which has enabled the identification of trends in poisoning, leading to public health improvements on everything from liquid detergent sachets to novel psychiatric substances.

The NPIS helpline is not open to the public, but is specifically targeted at health professionals.

“We receive calls from doctors, paramedics, nurses, and we’ve got a TOXBASE phone app as well.”

The Welsh Poisons Unit has made great progress in taking some of the pressure off the emergency department in Cardiff.

Now it is time to make sure that all patients are able to access liaison psychiatry services, wherever they live. It is time to treat the whole patient.

Jackson L. Lessons from the poisons ward: MDT working and the Welsh Poisons Unit. Commentary 2017;2:16–17. http://edition.pagesuite-professional.co.uk//launch. aspx?eid=83196a7d-a773-4922a7d8-5dbdd6950d24