WAPC Executive Director Medical/Clinical Leadership Report May 2020

CALL CENTER COMMUNICATIONS AND INFRASTRUCTURE (CI):

 WAPC has taken 3,481 calls regarding Covid-19  From 1/22 until 3/11, when the DOH Activation line was answered in our center, we took 2,689 calls for the DOH and 187 calls for the Local Health Jurisdictions  After 3/11, 605 calls have been taken on Afterhours and regular PC lines

IT/COMMUNICATION: Not all remotes are alike!  All poison center staff, administrative and call room, are working remotely. o Administrative staff are using a combination of personal computers and poison center laptops to VPN into their desks in the center; all are using personal cell phones. o Most call center staff working remotely have been provided with a poison center workstation and phone, they VPN into a virtual desktop. o Virtual desktops had not yet been set up for the newer call center staff (normally they would not be working remotely for another year) and we were short on equipment. John quickly purchased phones and computers from Amazon and additional computers from Best Buy. These staff VPN into the physical workstations in the call room. o CSW were provided with phones and workstations and VPN into a physical workstation in the call center. CALL CENTER STAFFING (CS):  CC Staff Remote Update: All CC staff, and Afterhours Contracted Student Workers (CSW), transitioned to remote workstations except one as of March 18th, 2020. This staff person worked safely in our office until 5/1, when she was able to secure home internet. We initiated this transition a week prior to Governor Inslee’s official “Stay At Home Order” on 3/23/2020, anticipating this order as well as wanting to ensure safety of our employees while continuing to provide our essential emergency 24/7 healthcare services, given the remote capabilities we already had in place for most of our CC staff.  LHJ After Hours Program: Due to the increased calls coming in on the Afterhour’s lines, we increased CSW coverage by 8 hours a week.

 CC Staff Years of Service Recognition: o March: Stephanie Garland PharmD CSPI: 2 years; Jared O’Connor MPH: 4 years o April: Amanda Lynn PharmD CSPI: 13 years; Lorelei Madriaga CSPI: 38 years  Virtual All-Hands Meetings: April 14 and 15, 2020

PATIENT MANAGEMENT (PM): Medical Direction Hours for April and May: These numbers include Phillips on-site and remote as Assoc. Med Director. UW Medicine, Seattle Children’s Hospital and Madigan Med Tox teaching hours are included in parentheses (x). Note: All Medical Direction including Rotator Education/Teaching transitioned to remote virtual activities as of March 17, 2020 due to Covid-19 pandemic and public health orders. Medical Director: 2019 NPDS Fatality Abstracts Completed and submitted – 38 total

Week Off Site On site Total Comments King County Medical Society Avg = 51 hrs 3/1-3/8/20 3 40(6) 49 Lead Stakeholder Mtg per week for 3/9-3/15/20 24 24(6) 54 ACMT Annual Scientific Mtg March; EMS and Trauma Steering 3/16-3/21/20 0 40 (9) 49 Committee (Virtual) Avg = 53.5

3/22-3/29/20 0 48(3) 51 hrs per week

3/30-4/5/20 0 56(6) 62 for April

4/6-4/12/20 0 48 48 4/13-4/19/20 0 48 48

4/20-4/26/20 0 48 48

4/27-4/30/20 0 40 40

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Real time Virtual Medical Director to Real time MD to CC SPI Education 4/30/20 Call Center (CC) Staff Education 4/8/2020:

Video Conferencing Virtual Education with SPI: -4-23-2020 QUALITY MANAGEMENT (QM):

 See May 2020 QMI Dashboard (attached )  Additional QM Activities to Support Remote Learning and Training were developed (such as the real time education above and the video conferencing education). o See the following attachments for additional information . Additional QMI activities . Coding . Remote CSPI supervision of PIP  Also developed was a process for e-filing o Sample sent item to Mara to e file. The email had the following subject: [e file] [staff name] [MD SPI EDUCATION & QA] [Communication folder] . E file (tells Mara what we want) . Staff name (tells Mara who this is regarding)

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. MD SPI EDUCATION & QA (all caps tells Mara that when she saves the PDF this will be the title) . Communication folder (tells Mara where to file it)

 Specific items saved (also e filed by Mara) to show remote supervision of staff o MD to SPI education- this is not specific to a person and includes whoever is online at the time, usually occurs via Instant Message Chat Room. It is one of the ways we provide education AND show that the medical director is aware of what is going on. o Quality Control- This is specific to an individual and examples, not every instance, should be saved to show that we are aware of what is going on and are actively providing feedback via Instant Message (since we are focusing on working remotely). We are initiating the interaction to assist with call handling for a specific individual. o Supervision by CSPI- This is where we show that ALL staff have support when they ask for assistance. We save all instances as these are process specific and not individual SPI. This shows when staff ask their peers for assistance they get help even though they are working remotely.

PUBLIC HEALTH EDUCATION:

March and April 2020:  Western Washington: 12 education events were completed reaching 378 residents.  Eastern Washington: 7 education events were completed reaching 460 residents.  Total: o 19 total events o 838 total residents o 1,295 Mr. Yuk stickers distributed

Our public education and community outreach underwent significant transformation in March and April due to the COVID-19 pandemic. All in-person presentations and outreach events were cancelled from mid-March to the foreseeable future. Meghan and Alex quickly shifted to setting up and providing virtual education, while Jared focused on emergency response in Spokane. Despite disruptions and new routines, our educators have maintained and grown our services to Washington communities.

In-person Education Our educators were very busy with in-person education at the beginning of March, prior to the public health measures restricting in-person events:  Jared visited Seattle during the first week of March, which enabled him to present on opioids and drugs of abuse to the Issaquah School District. Alex attended this presentation to better learn the talking points and identify areas for updating.  With Emma Gossard, our partner at the American Lung Association, Alex launched the newly revised E-Cigarette TOT to Stilly Valley Health Connections (located in Arlington). Meghan and Jared attended this presentation to offer feedback.  Meghan participated in a Resource Fair for ~150 parents/caregivers and kids at Stafford Elementary, located in Tacoma. Her booth shared general poison prevention tips and distributed Mr. Yuk stickers and magnets.  Alex and Jared completed a Central and Eastern Washington circuit during the second week of March. They presented to ESD 105 in Yakima, Walla Walla County Department of Community Health, and Benton-Franklin Health District in Tri-Cities. Topics included vaping, cannabis, and opioids.

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 Meghan presented the E-Cigarette TOT at the 2020 Communities for Families Community Summit (in Sumner). Audience members included teachers, school administrators, nurses, and local youth-serving organizations.

Virtual Education After increased public health measures resulted in the cancellation of all education events, our educators quickly shifted to virtual education. Meghan and Alex reached out to existing and new community partners to reschedule cancelled events as webinars, as well as to provide education on new topics.  King County Library System: Meghan and Alex formed a partnership with KCLS, and are providing a webinar every Thursday to any interested individuals (registration is not limited to KCLS members). Their first webinar consisted of a new presentation on preventing poisoning during the COVID-19 pandemic. This presentation explained why risk of poisoning is increased during the pandemic, then provided prevention tips with cleaners, hand sanitizer, medications, and intentional use. Other KCLS webinar topics included cannabis use in older adults, medication management, and lead poisoning prevention (a second new presentation). Upcoming webinars with KCLS will be our Vaping 101 and Cannabis 101 presentations.  Adult Family Homes Council of Washington: Meghan and Alex co-presented two webinars on cannabis use in older adults to members of the Adult Family Homes Council. Meghan will present on medication management to council members in June.  Spokane Regional Health District: Alex provided a virtual version of the Cannabis TOT to members of Spokane Regional Health District. This was our first attempt at a virtual training of this size – the training lasted 3 hours. While Alex received positive feedback from attendees, we will generally keep future trainings and presentations under two hours to maximize accessibility.  Au pair presentation: Meghan and Alex co-presented to an au pair audience in Seattle. The presentation covered general poison prevention with additional focus on poison risks during the COVID-19 pandemic.  Upcoming webinars: Alex and Jared will be presenting a series of three webinars with ESD 105 in May covering cannabis, vaping, and opioids. Alex is also working with Prevention Works in Seattle to schedule a cannabis training in June.

National Poison Prevention Week – March 15-21, 2020 Unfortunately, National Poison Prevention Week took place in the midst of our state’s rapidly changing environment with COVID-19. We were unable to take our Poison Prevention Poster Contest winner, Vivian Vuong, to Olympia, and were unable to present her with the Mr. Yuk Award of Excellence at her school’s assembly. We plan to reschedule these events for a later date.

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We were able to celebrate National Poison Prevention Week on social media. Based off of themes provided by the AAPCC, Meghan designed a series of posts that covered the top poison risks and prevention strategies for different age groups, a home “tour” for common household poisons, what to expect when you call the WAPC, and a thank you to our staff for their hard work and dedication.

Older Adult Education Meghan developed new educational materials for older adults on their increased risk of poisoning during the COVID-19 pandemic and appropriate poison prevention strategies during this time: a full length “guide” for older adults and older adult service agencies, as well as a shortened infographic. (See attached). These resources were sent to over 40 community partners, including senior centers and libraries across the state, statewide and local coalitions, health jurisdictions, and Fire and Rescue organizations. Many organizations agreed to distribute the resources through their networks, including in the Washington State Older Adult Falls Prevention Newsletter (see image), the Northwest Parkinson’s Foundation newsletter, the newsletter for the Washington Senior Lobby, resource pages for library systems, and Public Health – Seattle & King County’s Facebook page. She additionally wrote an article about older adult poisoning risks and the new resources for the May issue of AgeWise King County. The Washington Department of Health is currently translating the guide and infographic, and will post them on the www.coronavirus.wa.gov portal.

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COVID-19 Resource Page on WAPC website Meghan built a new page on the WAPC website to house resources and information specific to COVID-19. The page includes materials and recordings from community and clinical education, the older adult resources, a simple COVID-19 data snapshot, and media stories/interviews.

HEALTH CARE PROVIDER EDUCATION (HCE):

Rotators:  March 2020: 3 UW EM Residents, 5 Madigan EM Residents, 1 Madigan EMPA, 1 Creighton School of Pharmacy Student, 2 Paramedic students, 1 UW School of Pharmacy Student. total: 13  April 2020: 0  Total rotators March and April 2020: 13

Medical Director Rotator Teaching: March 2020: Liebelt 9hrs; Phillips – 3 hours Liebelt: UW Pharmacy student (virtual): 2 hours No EM rotators in April TOTAL: 14 hours.

WAPC Medical Director Teleconferences: March 13 and 27, 2020 April 13 and 27, 2020

Patient Care Guidelines:  Chloroquine and Hydroxychloroquine Case Management Guideline Developed 3/31/2020 – New  Chloroquine and Hydroxychloroquine Triage Guidelines 3/30/2020 - New  Calcium Channel Blocker overdose Fax Doc Updated April 2020  NAC Dosing and APAP Overdose Updated and Revised Guidelines/Process – pilot in progress

Healthcare Education Presentations:

Erica Liebelt MD:

3/25/2020 “Emerging Trends of Self-Poisoning from the Washington Poison Center” UW School of Nursing Ambulatory Care Conference Virtual Classroom

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4/7/2020 “EMS Poisoning Alert: Chloroquine and Hydroxychloroquine” Pierce County EMS and Emergency Management Webinar

DATA AND SURVEILLANCE (DS):

 Data Analyst o Dept. of Health Annual Report submitted o WAPC 2019 Top 10 released o King County City Grants data o Poisoning Trends during COVID-19 Pandemic – Visual Data Report to be released May 19 2020 o DATA sales in the last quarter: $250.00

LEADERSHIP & MANAGEMENT (LM)

Public Affairs and Community Relations

Development

• 2020 Hospital Fair Share Campaign :

• We have raised $436,750 as of 4/28/20 (May 2019 $432,750)

• King County Human Services Grants: Application submitted May 5, 2020, requesting $76,873.

Public Affairs

• Supplemental Capital Budget Request for 2020 Award Letter received $124K for updating and modernizing IT equipment related to COVID-19 emergency response • 2019 Capital Budget Award for $147,980 – contract in progress

Federal Legislative Update:

 CARES Funding: WAPC received Notice of Award on 4/23/2020: CARES Funding for Poison Centers to Washington Poison Center, Seattle, Washington is provided by the Health Resources and Services Administration (HRSA). The U.S. Department of Health and Human Services (HHS), through the Health

Page | 8 WAPC Vision: A region where poisoning and drug exposure are no longer the leading cause of unintentional death.

Resources and Services Administration (HRSA), awarded nearly $5 million to Poison Control Centers across the country to improve their capacity to respond to increased calls due to the COVID-19 pandemic. WAPC awarded $103,197. (See attached Letter to Senator Murray)

 Phone meeting with Congresswoman Kim Schrier MD 5/1/2020, U.S. Representative WA 8th Congressional District; first pediatrician to be elected to Congress

Emergency Response and Preparedness: Jared assisted Spokane Regional Health District (SRHD) with their response to the virus. Jared joined a team at SRHD that partnered with Providence Healthcare to plan, set up and operate Spokane’s main COVID-19 testing center at the Spokane fairgrounds as well an isolation center for COVID-19 + homeless individuals. In addition, Jared assisted SRHD by organizing, inventorying and distributing their supply of PPE.

Media/Community Relations:  Meghan has posted extensively on social media in the past 2 months. Many posts have focused on poison prevention during the COVID-19 pandemic, but she has continued to share other messages relevant to the season, upcoming events, and resources from community partners. In March and April, our Facebook account reached 36,709 people with 2,420 engagements (likes, shares, comments, etc.). We additionally gained 50 new page likes and 57 new followers.  On 4/20/2020, we issued a Press Release: Washington Poison Center Notes Increase in Poison Exposures During the COVID 19 Pandemic (see attached WAPC in the Media during COVID Pandemic – Promoting Prevention). The press release was distributed via PR Newswire and on the WAPC’s MailChimp listserv (to 188 individuals). o Media reach: 264,114,864  In the month of April, Erica and Meghan participated in a total of 12 interviews with local media: 3 newspaper interviews, 6 TV interviews, and 3 radio interviews (see photo of Erica with Joel Moreno, KOMO News). All interviews focused on increased risk of poisoning during the COVID-19 pandemic, especially with household cleaning products and hand sanitizer. Many interviews stemmed from the CDC’s MMWR article on increases in poison exposure calls nationwide, as well as the WAPC’s press release on increases in Washington.

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 On 3/31/2020, we issued a Public Health Alert re: Chloroquine and Hydroxychloroquine Poisoning from the Washington Poison Center (see attached). The Public Health Alert was faxed to emergency departments and sent via MailChimp for additional email distribution.  On 4/28/2020, we issued a Seasonal Health Alert on Lawn and Garden Care. The alert was sent to 509 individuals, including media, health jurisdictions, and community members.  Met with Brett Nelsen and Will Harris, KOMO TV to discuss PSA partnerships for WAPC (4/29)

Human Resources: Erica with Joel Moreno, KOMO News

• Leadership and Administration Virtual Strategic Planning Retreat: April 6, 2020 • Steve Burgon JD , Board President and AJ Dotzauer, WAPC Lobbyist participated • Reviewed WAPC’s Mission, Legislative Mandates, AAPCC Accreditation requirements and discussed how to integrate and fulfill all in reviewing, updating, and developing our strategic priorities, especially, given the changing landscape of our public health environment

• HR Handbook is still being reviewed and updated • Numerous Operational and HR Policies have been reviewed, updated and/or developed • Families First Coronavirus Response Act (FFCRA) resources distributed to all staff.

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Other Relevant Meetings for Executive/Medical Director:

3/14/2020 American College of Medical Toxicology Virtual Annual Scientific Meeting Erica L. Liebelt MD awarded 2020 Matthew J. Ellenhorn Award, given to honor an individual who has made extraordinary contributions to the field of medical toxicology “Keeping the Lamp of Excellence Burning: Important Lessons a Heart Surgeon and Medical Toxicologists Have Taught Me”

Virtual Presentation: Dr. Fred Henretig introducing Erica Liebelt for her Ellenhorn Award Acceptance and Virtual Home Presentation!

Research:

Abstract accepted to Pediatric Academic Society Meeting to be held May 2020 but cancelled due to COVID- 19 pandemic: Parrish H, Von Derau C, Mazor, S: “Characteristics of epinephrine auto-injector injuries reported to the Washington Poison Center”

Annual Report 2019: distributed May 6, 2020; on WAPC website

BOARD UPDATE

Andy Cheung MBA: Featured in Seattle Times Give Big section on April 26, 2020. Thank you Andy for talking about your service on the Board of Directors at the WAPC! Thank you for “jumping in and serving” your community and our organization. (See attached article)

Governance committee: • Vice-President/President- elect for next 2 year term is still vacant. • Final Approval of 3 Board Policies: Whistleblower Policy, Conflict of Interest Policy, and Procurement Policy via electronic Board vote on 4/7/2020

Finance Committee:  See Executive Summary of Finances on Board secure portal.  Financial Reports are on the Board secure portal  Accounting Firm proposals in response to our RFP reviewed at FCM 4/28/2020

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 HRSA Financial Management Review (FMR): received our letter of completion on April 13, 2020 stating WAPC is in compliance with federal requirements to receive federal funds.  WAPC awarded $103,197 through HRSA from CARES Act federal funding  WAPC awarded $120,280 through Washington state Supplemental Capital Budget Award

IT Committee:  The IT Committee met virtually on 4/16 and reviewed the 2019 and 2020 capital budget requests. Both will be reimbursements for previously purchased IT equipment, audio/visual equipment, or furniture used to provide trainings related to COVID-19.  Due to the huge COVID-19 inbound call volume (thousands of calls) in early March, our two PRI lines (46 ports) were blocked, resulting in no inbound or outbound calls being made. This necessitated an emergency change to our PRI configuration, one PRI for PC calls and one for public health calls. Additionally, we added 70 lines on a separate circuit. Our vendor, Allstream, worked with John to accomplish this in about 4 days, rather than the usual 4 weeks.  Due to the ability of working remotely, WAPC will be exploring various platforms to allow staff collaboration, such as Slack and Microsoft Teams.

Attachments within this report:  Dash Ed  May 2020 QMI Dashboard  Additional QMI activities  Coding  Remote CSPI supervision of PIP  Department of Health Letter of Support  Public Health Alert: Chloroquine and Hydroxychloroquine Poisoning  Older Adult Poison Prevention: Prevention Strategies During the COVID-19 Pandemic April 2020  Thank you Letter to Senator Murray for CARES Act Funding to Poison Center Network  WAPC in the Media during COVID Pandemic – Promoting Prevention  AgeWise King County “Increased Risk of Poisoning During the Pandemic”  Andy Cheung, MBA Seattle Times Give Big

Other attachments:  Board Meeting Minutes March 2020  2019 Annual Report

Note: All Financial reports are on the secure Board of Directors’ portal

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155 NE 100th Street, #100 Seattle, WA 98125-8007 Phone: 206.517.2350 DashEd.Comm Fax: 206.526.8490 Mar – Apr 2020 www.wapc.org

Map of Public Health Education in 2020

Equal Opportunity Employer — 501(c)(3) Nonprofit Organization Quality Management & Improvement May 2020 Dashboard

Medical Director HCF Daily Reviews Peer-to -Peer Documentation Review (Reviewed for coding- no metric) Metric: > 10 % of cases will be reviewed 40% 35% Apr 30% 25% 20%

15% Mar

Percent Percent Reviewed 10% 5% 0% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Jan Feb Mar Apr Percent QA'd cases coded correctly Percent of cases fitting criteria that were QA'd

Include any AAPCC benchmarking Monthly Calls Reviewed by CCL Monthly Case Record Reviews by CCL and and Mgr Dir Mgr Dir o Provide consistent metrics Quarterly (#sent, #delivered, #returned, time to complete, %completed) 7,000 2.5% 7,500 7%

6,000 6% 2.0% 6,000 5,000 5% 4,500 4,000 1.5% 4% 3% 3,000 1.0% 3,000 2,000 2% 1,500 0.5%

Recorded Recorded inbound calls 1% Percent of calls calls reviewed of Percent

1,000 Number cases of per month

0 0% Percent of case records reviewed 0 0.0% Jan Feb Mar Apr Jan Feb Mar Apr Inbound Poison Calls Cases not already reviewed as part of Med Dir QA Metric: at least 1% of recorded calls will be reviewed Metric: >5 % of cases will be reviewed

HCF Fax Survey Caller Satisfaction Survey Metric: 104/year (avg 8 per month) Metric: 384 Surveys Annually* 14 3.0% 250 12 2.5% 200 179 183 10 159 2.0% 144 8 1.5% 150 6 4 1.0% 100 0.5%

2 50 Number Number Surveys of Completed Completed Surveys 0 0.0% Jan Feb Mar Apr 0 Jan Feb Mar Apr Number of Returned Surveys Percent of surveys returned from faxes sent Completed Surveys received * Total 665

1) Medical Direction a. Review 5 additional Closed Healthcare Facility cases per week each for each of the new staff that would not yet have been working remotely. Our documentation needs to only be the “Medical Director “ key cut and there is not a need for additional documentation on an Excel Spreadsheet. i. These reviews will be focused on clinical assessment and recommendations, documented primarily in the note section. ii. Feedback should be given to individual SPIs either real-time or via email. b. One new staff is not in the HCF queue and will receive one-on-one guidance and training with the medical director. c. Will continue the “normal” open HCF Director review cases defined by the Search criteria in toxiCall. d. Areas of concern will be brought to the attention of the Managing Director or Call Center Leads.

2) Call Center Leads a. Increase off line time from 50% to 100 % to ensure ability to supervise new staff b. Altered their work schedules to decrease overlap and increase supervisory coverage c. Increased reviewing all non-CSPI HCF for the first week remote, if problems identified will continue reviews d. One new staff not in HCF queue- review all cases e. Random daily reviewing Tape to Chart comparison to ensure accuracy for all newly remote staff (regardless of employment duration), including monitoring for call to chart consistency throughout shift. f. Real time case discussions via pigeon g. Real time case discussion via phone h. Watching caller hold time via Real Viewer and offering immediate/real-time assistance i. Monitoring call length 3) Managing Director a. Increase random/spot tape reviews- providing feedback b. Increased random/spot chart reviews- providing feedback, primarily coding c. Created a process for filing remote feedback

QM Activities to support remote working Date: 4/17/2020 Equal Opportunity Employer — 501(c)(3) Nonprofit Organization Katie Von Derau

From: Hanh To Sent: Friday, April 17, 2020 2:24 PM To: Mara Piwen Subject: [e file] [SUBSTANCE CODING] [T:\AAPCC\AAPCC Cert\Remote Workers\Quality Control]

Got it, thanks Katie!

-Hanh

On Apr 16, 2020, at 6:07 PM, Katie Von Derau wrote:

Hanh, when reviewing this case I made the following changes (in yellow below). I did not return it to you, but I did want you to know what I’d done and why.

--- Mon Apr 13, 2020 @ 16:39 By 338:To, Hanh --- * HISTORY provided by caller: 67 yo female sprayed 1 spray in each nostril with Fixodent powder thought it was saline, happened 6 hours ago. * Product/Substance: Fixodent powder Fixodent Powder – Regular- changed from generic code to this product specific code * Medical History: healthy * Symptoms since exposure: inside ears itch- improving Coded dermal pruritus as unk if related * Initial Therapy Provided: been using saline x 5 Changed from * Amount Justification:: 1 spray each nostril, per pt report * PC Assessment (risk to patient): can cause nasal/respiratory irritation, sx is improving, would expect sx to continue to improve. * PC Recommendations/Plan: recommend to blow out nose and clean around nostril with cotton swab. Call back in 1 hour to give update. Call back PRN. * Resources Used: PI

Katie

1 Katie Von Derau

From: Katie Von Derau Sent: Wednesday, April 8, 2020 1:53 PM To: Erica Liebelt Cc: Katie Von Derau Subject: CSPI supervision of a PIP remotely

(1:49:18 PM) dserafin: 57 yo F on 1 to 2 Percocet 5/325 q 4 hours, in ED altered due to EtOH, has APAP of 32 (ref range 10 - 30 per lab), AST 60 and ALT WNL. Is that APAP level concerning for NAC? (1:49:54 PM) pcole: any timeframe for last dose? (1:50:08 PM) pcole: but no, I don't think so (1:50:40 PM) dserafin: patient not too reliable due to EtOH 461, says none today (1:51:22 PM) pcole: In that case it might be (1:51:53 PM) kwhite: seems iffy, might be worth treating to be on the safe side (1:52:14 PM) dserafin: I was leaning that way, thanks

Katie

1

STATE OF WASHINGTON

DEPARTMENT OF HEALTH

PO Box 47890  Olympia, Washington 98504-7890 Tel: 360-236-4030  711 Washington Relay Service

April 7, 2020

Erica L. Liebelt, MD, FACMT Executive Director/Medical Director Washington Poison Center 155 Northeast 100th Street, Suite #100 Seattle, Washington 98125-8007

Dear Dr. Liebelt:

The Washington State Department of Health (DOH) appreciates the long partnership we have had with the Washington Poison Center (WAPC). WAPC’s 24/7/365 emergency poison help line provides information and recommendations to the public and healthcare providers that no other agency provides. Their overall education/community outreach programs focused on poison prevention—from medications to e-cigarettes to household chemicals—have been especially helpful to the public health system as a whole.

Other ways the Poison Center has been a unique partner:

• Poison Helpline: Receiving calls from concerned families 24 hours a day, 7 days a week, 365 days a year, WAPC provides immediate expert treatment guidance to families and individuals who have ingested or been exposed to poisonous, hazardous, or toxic substances. • Poison Prevention Public Education: Through DOH’s Child Profile mailings, community health educator trainings, and many public events, WAPC provides parents and caregivers across Washington with excellent guidance and resources to prevent unintentional poisonings among children. (For example, Mr. Yuk stickers, which are part of our one-year Child Profile mailing, warn children that something in the home is dangerous, and include the Poison Center hotline number.) • Emergency Response: o Helping during the 2019 Measles Outbreak by standing up a call center to answer questions from concerned public members. While the bulk of the outbreak was centered in Clark County, WAPC responded to phone calls from people across Washington State. o Providing support during the first month of the 2020 COVID-19 outbreak by standing up a statewide call center to answer questions from the public. • Local Health Jurisdiction Public Health Support: Providing ongoing support to seven local health jurisdictions for after-hours calls, as well ongoing support for their COVID-19 calls.

The strong, collaborative partnership this organization has with the state and local public health system on many levels is critical for carrying on the important mission of the Department of Health—to work with others to protect and improve the health of all people in Washington State. We look forward to continuing our successful partnership with the Washington Poison Center.

Sincerely,

John Wiesman, DrPH, MPH Secretary of Health

PUBLIC HEALTH ALERT Questions? Contact the Washington Poison Center 24/7/365 at 1 (800) 222-1222. Media contact: [email protected]

Issued: March 31, 2020

Chloroquine and Hydroxychloroquine Poisoning

Chloroquine (CQ) and Hydroxychloroquine (HCQ) are medications often used to prevent and treat malaria and other rheumatologic disorders such as lupus and rheumatoid arthritis. Their use is currently being studied in treating patients with confirmed coronavirus (COVID-19) disease. These prescription medicines should only be taken under the supervision of a prescribing healthcare provider for approved indications.

WHAT IS THE CONCERN?  To “prevent” contracting coronavirus, some people are trying to obtain CQ and HCQ via non-regulated markets, such as on the internet, and/or by buying non-medical forms that are not meant for human ingestion (e.g. fish tank cleaner). Using these non-prescribed forms of CQ and HCQ has resulted in severe poisoning and, in some cases, death.  CQ and HCQ have narrow therapeutic margins and can result in significant clinical toxicity with therapeutic errors, inappropriate dosing, and interactions with other drugs.  Deaths have been reported in young children ingesting 1-2 tablets and older children and adults with ingesting only 3-5 times the recommended dose.  Clinical Toxicity and Evaluation:

Onset: 1-3 hours Clinical Toxic Effects: Labs & Monitoring:

Duration: hours to - GI: Nausea, vomiting, diarrhea - Blood Pressure days, although death - ECG: QRS widening and QT - CNS: Agitation, sedation, seizures, coma. Psychosis has been reported in and hallucinations may occur in pediatric patients. prolongation

the prehospital setting - Resp: Respiratory depression, apnea - Basic metabolic panel - CV: Hypotension, bradycardia, wide complex - K+, Ca2+, Magnesium tachycardia, ventricular tachycardia, ventricular - CBC for hemolysis fibrillation, Torsades de pointes - CQ and HCQ levels are not - Electrolytes: Hypokalemia, hypoglycemia helpful acutely - Eye: Blurred vision, diplopia, photophobia, transient blindness - Heme: Hemolysis, especially patients with G-6PD deficiency

TREATMENT  Early aggressive supportive management of severe toxicity: Intubation, Mechanical Ventilation.  Unique therapies for the severe cardiovascular toxicity have resulted in improved outcomes and are time sensitive: High Dose Epinephrine and High Dose Diazepam.  Please call the Washington Poison Center for immediate assistance and consult with our physician Medical Toxicologists for further indications and details.

155 NE 100th Street, #100 Seattle, WA 98125-8007 P: 206-517-2350 F: 206-526-8490 www.wapc.org OLDER ADULT POISON PREVENTION Prevention Strategies During the COVID-19 Pandemic

WASHINGTON POISON CENTER APRIL 2020

Higher risk of severe illness from COVID-19 places increased importance on social distancing for older adults (ages 60 and older). For many older adults, however, the changes stemming from social distancing measures are decreasing access to basic needs and services, disrupting daily routines, and causing isolation, stress and anxiety. All of these changes place older adults at higher risk of poisoning, both accidental and intentional.

Strategies for older adults to mitigate poison risks during the COVID-19 pandemic are summarized below. Further risk and strategy explanations are available in an extended guide, located at: https://www.wapc.org/wp-content/uploads/WAPC-Older-Adult-COVID- Poison-Prevention-Guide.pdf. MEDICATION ERRORS Changes to daily routines, distractions, stress, and potentially decreased caregiver support may increase risk of medication errors, such as double dosing or taking the wrong medication. Use a physical system to track when medications are taken, such as a medication checklist, cell phone reminder app, or pill box. Keep medications in their original containers or pill box, never loose. Store medications in separate locations or add labeling to differentiate between the medications of different household members and pets. To prevent double dosing, read medication labels closely (especially dosing recommendations and ingredients). Add labeling (stickers, tape, permanent marker, etc.) to clearly differentiate between "look-a-like" products. Call the Poison Helpline with any questions about medications, dosing, or if a medication error occurs. SELF-MEDICATING There are currently NO approved medications, vitamins, or other substances to treat or prevent COVID-19. Using products that claim to do so can have serious or even life-threatening effects. Talk to your doctor/pharmacist or call the Poison Helpline before taking a new medication, vitamin, or supplement. Ask about any health or safety considerations specific to your health and current medication. Never ingest disinfectants (like bleach) or non-pharmaceutical substances that claim to prevent or treat COVID-19. Call the Poison Helpline if you are unsure if a substance is safe.

CLEANERS & DISINFECTANTS

Read and follow all directions and safety warnings. Open windows and doors to ensure adequate ventilation. Wear gloves when using products. Do not mix cleaning products, and be careful cleaning with different products back-to-back. Mixing products can produce toxic gases. Store cleaners, household chemicals, and other potentially harmful products in their original containers. Label products with Mr. Yuk stickers or other quickly identifiable labeling that shows a product may be unsafe. Store products up high and out of reach of young children.

GRANDPARENTS Some older adults may be helping with childcare, which can pose poison risks for both the older adult AND the child. Take medications out of sight of children. Check the carpet/floors for dropped medication. Use medication management strategies to ensure distractions and new daily routines do not lead to medication errors. Store all medications, cleaners, sanitizers, and other potentially harmful substances out of sight and out of reach of young children. Always supervise children when using hand sanitizer. Hand sanitizer has high alcohol content, and can lead to alcohol poisoning in children if ingested. Call the Poison Helpline immediately if hand sanitizer is ingested.

INTENTIONAL USE

COVID-19-related isolation and stress may place even more older adults at risk of developing or increasing anxiety and depression, which in turn may increase use of substances and/or risk of self-harm or suicide. Take a break from the news. Set up regular communication with family members and friends. With so much uncertainty, it is helpful to establish periods of certainty, connection, and support. Reconnect with organizations or social connections that were an important part of your life pre-COVID-19 pandemic. Many of these organizations are setting up ways to support their members virtually, over the phone, or through other means. If you or someone you know needs emotional support or is thinking of suicide, contact the National Suicide Prevention Lifeline: 1-800-273-8255. For immediate help after self-harm, call 911.

For help with any questions or emergencies with potential poisons, CALL THE POISON HELPLINE AT 1-800-222-1222.

The helpline is available 24/7/365, even during this pandemic. All calls are free and confidential.

Find additional COVID-19 resources and information at: https://www.wapc.org/programs/covid-19-resources-information/

April 1, 2020

The Honorable Patty Murray 154 Russell Senate Office Building Washington, DC 20510

Dear Senator Murray:

Thank you for your ongoing support of the Poison Control Center (PCC) program and for including $5 million to improve the capacity of poison control centers to respond to increased calls during the COVID-19 pandemic in the Coronavirus Aid, Relief, and Economic Security (CARES) Act (Public Law 116-136). This funding is critical to the continuing operation of the national network of 55 poison control centers including the life-saving center in Seattle. As of the morning of March 29, poison centers have received over 177,000 calls on the coronavirus from citizens and health care facilities from all 50 states and most U.S. territories. This funding is critical to assist our centers in responding to this health emergency as well as the long-term impact it will have on our nation.

We also want to take this opportunity to express our sincere thanks to Kelly Brown of your Labor-HHS Appropriations Subcommittee professional staff. She is wonderful to work with and represent you and the state of Washington with professionalism and grace. Finally, if you or your staff ever need data or any additional information on our work, please do not hesitate to ask. Thank you again, Senator, for your strong support of our centers. We are incredibly grateful.

Warmest regards,

Dr. Mark Ryan Dr. Erica L. Liebelt President, AAPCC Executive Director/Medical Director Director, Louisiana Poison Center Washington Poison Center

4601 N. FAIRFAX DRIVE, SUITE 630 ARLINGTON, VA 22203 MAIN: 703.894.1885 FAX: 703.683.2812 E-MAIL: [email protected] WWW.AAPCC.ORG MAIN 703.894.1885 FAX 703.683.2812 E-MAIL [email protected] WWW.AAPCC.ORGkbjv4601 N. FAIRFAX DRIVE, SUITE 630 ARLINGTON, VA 22203 WAPC in the Media during COVID Pandemic – Promoting Prevention

TV interviews 4/21 & 22/20 Radio Interviews 4/2 & 4/8/20 KOMO News – People accidentally poisoned by KOMO NewsRadio – COVID-19 Related Calls to the household cleaners spike since stay-home order Washington Poison Center KGMI – Cleaning Supplies and Accidental Poisoning

Q13 Fox – Washington Poison Center sees increase in poison exposure calls during pandemic

KUOW - Health officials worry about accidental poisonings during outbreak KXLY – WA Poison Center sees increase in exposures to DOH JIC Report 4/22/20 household cleaning products

KING 5 - Washington Poison Center sees uptick in calls after stay home order KIMA CBS Yakima – Increases in Household poisoning Exposures at WAPC during COVID KIRO TV – Increasing Hand sanitizer and household cleaning product exposures during COVID 19 pandemic

Newspaper: Seattle Times 4/21/20

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