Gr. Bond et al., ACETAMINOPHEN INGESTION IN CHILDHOOD - COST AND RELATIVE RISK OF ALTERNATIVE REFERRAL STRATEGIES, Journal of toxicology. Clinical toxicology, 32(5), 1994, pp. 513-525
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.