ACETAMINOPHEN INGESTION IN CHILDHOOD - COST AND RELATIVE RISK OF ALTERNATIVE REFERRAL STRATEGIES

Acetaminophen is the pharmaceutical most frequently ingested by small children. Although past research has allowed the safe management of 90 % of these ingestions at home, several thousand are still referred to emergency departments annually. With the goal of further reducing the number of unnecessary referrals, the risk/benefit considerations of al ternate referral strategies were analyzed. In a retrospective poison c enter chart review study from 11 centers, the records of children betw een the ages 1 and 6 years who acutely ingested acetaminophen and were referred to a hospital for determination of serum acetaminophen conce ntration in 1986 and 1987 were identified using the database of the Am erican Association of Poison Control Centers. Risk of hepatic injury w as assigned on the basis of the Rumack-Matthew acetaminophen toxicity nomogram. The cohort was stratified in terms of the amount ingested an d whether a pediatric or adult preparation was ingested. The direct co st of an evaluation was estimated from four centers. Sensitivity, spec ificity and direct cost of each risk identification strategy were calc ulated. Eight hundred sixty six of 2091 patients had a timed serum ace taminophen concentration recorded. Of these, three patients had result s in the ''probable risk'' area of the nomogram. A referral reduction strategy which would refer only children who ingest 200 mg/kg or more of an adult preparation could eliminate 82% of referrals without missi ng any of these ''probable risk'' patients. Six other children were de termined to have serum acetaminophen concentrations in an area of the nomogram labeled ''possible risk''. No referral reduction strategy exp lored identified all of these patients. The average charge for an emer gency department evaluation in 1992 was $272.00. These data suggest th at children less than six years of age who ingest pediatric acetaminop hen products other than those from packages containing greater than 30 tablets or who ingest less than 200 mg/kg of an adult preparation may be safely managed at home without referral to a hospital. This strate gy would result in significant cost savings and prevent unnecessary in convenience to many patients and families.