OVER THE COURSE of their career, nurses develop the knowledge and skills to deliver the best quality care relative to individual patients and their families. Although many nurses enjoy working in fast-paced departments such as the ED and ICU, the work can be physically and mentally exhausting. This article discusses a career in toxicology as a specialist in poison information (SPI), which gives nurses another option in the healthcare field that also offers the teaching opportunities, independence, and challenges of the nursing profession.
In the US, over 2 million human poisonings and about 40,000 deaths are documented annually, with a poisoning occurring approximately once every 14 seconds. Most of these poisonings happen in children age 6 years or younger.1,2 Poison control centers (PCCs) across the country provide medical information and interventions to manage these suspected poisonings at a cost savings of over $1.8 billion to the healthcare industry as of 2016.3,4
Nurses draw on their education and experience to administer drugs safely. This knowledge can be easily expanded to encompass toxicology. Using toxidromes, or signs and symptoms associated with toxicity, toxicologists learn the maximum quantity to which an individual can be exposed before a substance becomes toxic. Toxicologists also have in-depth knowledge of pharmacokinetics, including a drug's half-life, elimination rate, and distribution volume.1,3
Toxicology requires constant education regarding new drugs and consumer products, as well as the antidotes to toxic components. Toxic exposures can occur via many routes, including ingestion, inhalation, and dermal contact. Treatments are determined according to the classification of the drug or toxic substance. Just as treatment differs for toxicity from a benzodiazepine versus an opioid, treatment differs when a caustic substance is involved versus a corrosive substance.1,3
Qualifications and certifications
SPI training includes learning about potentially toxic medications, street drugs, plants, chemicals, pesticides, metals, and gases. Additionally, SPIs also learn about US packaging laws and what substances are considered fatal if used in small quantities.5 Packaging laws require specific quantities and container sizes to reduce the risk of childhood poisoning. SPIs are trained about their role in mass casualty incidents, hazardous materials incidents, and/or terrorist events.1,6
A nursing license is required for someone to be eligible for work as an SPI, and most PCCs require SPIs to become certified. Although ED and ICU experience is a plus, it is not required. A Certification for Specialists in Poison Information exam is offered annually through the American Association of Poison Control Centers (AAPCC) to eligible applicants once the following qualifications are met:1
- current employment with a certified PCC
- the completion of 1,200 hours of experience providing telephone poison consultations
- completion of 2,000 hours of documented human poison cases
- recommendation from a PCC medical director.
Candidates have 4 hours to complete the exam, which “contains 160 to 165 questions, of which only 125 will be used to determine the candidate's score.”7 These include computer-generated questions, direct questions, and case scenarios from all areas of medical toxicology; for example, general principles of poison management, general history, mathematical calculations, biological agents, chemicals, metals, gases, drugs, household products, pesticides, toxidromes, lab testing and results, and ancillary testing.8 Many PCCs also require new SPIs to be mentored for up to 6 months before answering calls independently. Training is provided by a senior certified SPI who acts as a preceptor.
The role of SPIs
A poison center may be located within a hospital setting as a program of that facility or located in an ED as a service offered by the hospital. SPIs work with other healthcare professionals across the spectrum of the healthcare system. These may include emergency medical services (EMS) first responders, paramedics, police officers, pharmacists, nurses, and physicians. They attend in-house daily toxicology rounds and may present research in toxicology at national conferences.
Their primary role and function is to answer emergency hotlines and offer guidance to both the public and healthcare providers on what treatments or interventions may be necessary in the event of an exposure.1 Additionally, SPIs are responsible for obtaining specific patient information, including signs and symptoms, time of exposure, and any ingested substances, ingredients, or quantities to determine the occurrence of a poisoning.
If a patient requires immediate care, the caller is directed to contact EMS and the SPI should notify the local ED regarding any suspected poisonings. The SPI also educates callers about substance toxicities, treatments, interventions, antidotes, and recommendations for continued care or observation. If a toxicologist consultation is required, the SPI may also contact an on-call toxicologist.
Accredited PCCs are required to follow up on all suspected poison cases, including patients sent to the ED, and each should be thoroughly documented in the electronic health record (EHR). All PCCs generate a PCC-specific EHR. The record supplies the AAPCC with poison exposure data for its annual surveillance report. Original patient records are kept in-house in the PCC and are discoverable in the event of an intentional or malicious poisoning.
Using analytical skills to manage emergency calls under stressful conditions, SPIs must be critical thinkers capable of working both independently and with a team. The role requires consistent communication with physicians, nurses, pharmacists, police, EMS personnel, and the general public.
Besides providing thorough documentation of each case in the EHR, SPIs also attend medical teaching rounds and present cases to staff. They are encouraged to publish toxicology-related research and should continually educate themselves regarding the management of new drugs and products. To address this, many PCCs offer continuing-education training for all staff, as well as opportunities to attend national toxicology seminars.
A good fit with nursing
Given the flexibility of the profession, nurses are fortunate to be able to move across professional settings in both healthcare and nonhealthcare environments. A background in toxicology opens doors to toxicology-specific fields, including legal nursing, forensics, environmental and occupational nursing, pharmaceuticals, public health, toxicology treatment centers, teaching, research, and writing. Nurses looking for a change of pace without abdicating their calling should consider this specialized profession.
1. Gummin DD, Mowry JB, Spyker DA, Brooks DE, Osterthaler KM, Banner W. 2017 Annual report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 35th annual report. Clin Toxicol (Phila). 2018:1–203.
National Capital Poison Center. Poison statistics: National data 2016. http://www.poison.org/poison-statistics-national.
The Lewin Group. Final report on the value of the poison center system: white paper. American Association of Poison Control Centers. 2012. https://aapcc.s3.amazonaws.com/files/library/Value_of_the_Poison_Center_System_FINAL_9_26_2012_--_FINAL_FINAL_FINAL.pdf.
American Association of Poison Control Centers. 2017. http://www.aapcc.org.
Government Publishing Office. Content details: 16 CFR 1700.14 - substances requiring special packaging. 2003. http://www.govinfo.gov/app/details/CFR-2003-title16-vol2/CFR-2003-title16-vol2-sec1700-14.
6. Sutter ME, Bronstein AC, Heard SE, et al The role of clinical toxicologists and poison control centers in public health. Am J Prev Med. 2010;38(6):658–662.
Pearson Vue. CSPI exam sponsored by the AAPCC. https://home.pearsonvue.com/aapcc.
Sandler LJ. 2012 CSPI Exam Candidate Handbook. American Association of Poison Control Centers. 2012. http://www.pearsonvue.com/aapcc/CSPIExamCandidateHandbook.pdf.
American Association of Poison Control Centers. National poison data system annual reports. 2017. http://www.aapcc.org/annual-reports.
National Capital Poison Center. Poison control. 2018. http://www.poison.org.