The Ethics of the Turkey File

[paramed2premed]

Who uses a "turkey file," an case of index cards with the names of 'drug-seekers' in it? It seems like most EDs have one, even if they swear to JCHAO that they would never do such a thing. What with HIPPA taking over, it seems that maintaining one would get a little more risky.

More importantly, what are people's thoughts on both the utility and ethics of using them? Are the legal risks worth it?

Personally, I feel they prejudice the nursing and medical staff; I have seem many patients come in labeled as "seekers," only to find they have a real malady. Of course, they have some usefulness on occasion.

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[Annette]

Are you refering to plans and agreements made between patients, their pain care specialist, and the ED? Gobble, gobble.

I think they are a quite reasonable tool, and ethical if the patients are included in making the plans. I don't like being suckered, I don't like leaving people in pain. The plan gives everyone a guide line as to what to expect. I don't have to worry that I'm upsetting a treatment plan in place, and the patient knows what to expect when they come into the ED.

 

[docB]

Let me start by saying that we don't have an actual frequent flyer file where I work. We just know them all. For example I discharged the same guy from the ER four times in one 12 hour shift about a month ago (a new institutional record).
I think that JACHO and HIPPA (or as I refer to them "the antichrists") frown all over the lists because they are a separate and unsecured medical record. They don't like the idea that patients, lawyers or auditors might not have access to everything that we know.
Ethically I have no problem with it. It's really no different than writing something unflattering in a patient's real chart such as "history of drug seeking", "history of manipulative behavior" which are frequently noted.
As for dreg seeking in general as a drain on the ER and a clinical entinty, that would be a whole other thread.

 

[paramed2premed]

Agreed, docB, the topic of defining and treating the putative "drug-seeker" is a topic distinct from that which I hoped to discuss.

Annette, I am not describing contracts made between physicians and patients regarding their treatment. What I am calling a turkey file (a term used only in the northeast?) is a file of index cards kept hidden at the ED desk. Each card contains a patients name and a very brief chronology of that patient's visits to the ED, e.g.

12/08/01 back pain demerol 125 IM, Percocet #5
02/10/02 back pain Toradol 60 IM, left AMA
03/15/04 shoulder pain morphine 2 mg, did not f/u

Patients have no idea that such a file exists.

The physicians in my ED have varied approaches to using the file. Some will pore over the file, looking for psuedonyms, relatives, and friends of the patient. Others do not even check the file, stating that such information will not affect managment.

I am a paramedic now, working in a 30k visit/year ED, as well as on the ambulance. In many areas of medicine, I feel I have an idea of how I would procede if/when I become a physician. Treating the suspected "drug-seeker" is not one of those areas! I am interested in all thoughts on this matter.

By the by, I hate the term "drug-seeker." I feel it lacks any precise definition, is pejorative, and is conflates many factors.

Interestingly, we are undertaking a huge renovation of the ED to comply with HIPPA, but the T-file stays!

 

[deleted6669]

we use the term patient management guide and the dx monitor opiate use. more p.c., but still a frequent flyer book.

 

[Annette]

Where I rotated, they had a computerized system that you could look up (and were very much encouraged to) previous visits to the ED. So, no index cards needed!

 

[ERMudPhud]

In the computer era a card file probably isn't real necessary. If I am at all suspicious I can look up the dates and d/c diagnoses for the patients last 3 years worth of visits in about 10 seconds. One hospital I worked at even printed out that page and attached it to the back of the current visit. Our Pyxis also keeps a several monthl record of meds ordered for each patient so I can look up what they were given in another 10 seconds.

I usually give everyone the benefit of the doubt once but I tell them that the ER is not the right place to treat chronic pain and that they need to discuss a pain plan with their PCP/Pain doc, including a plan for breakthough pain which isn't just "go to the ER". I then note this in my dictation. That way if I continue to see them I feel less guilty about refusing them narcotics.

 

[docB]

We just took a step back in our computer and I can no longer tell how many ER visits a patient has had. Regardless, I always keep my own turkey file in my head.

 

[docB]

I thought I?d bump this thread because there is an article about this very issue in the new Annals of EM (June, 2003, p873). The article is by Joel Geiderman of Cedars-Sinai in LA. It?s titled ?Keeping Lists and Naming Names: Habitual Patient Files for Suspected Nontherapeutic Drug-Seeking Patients.?

Highlights:
Dr. Geiderman discusses turkey files in terms of ethics, state and common law, HIPPA, EMTALA and JCAHO. Interestingly it turns out that there is no specific prohibition against turkey files (I thought there was).
A description of the Cedars-Sinai model for establishing an electronic based, multidisciplinary reviewed turkey file.
A suggestion that we use the term ?nontherapeutic drug-seeking patients? to describe the worst of the worst, the guys who want to sell their scripts or are truly just looking to get high. This would separate them from the drug-seeking patients who suffer from real of perceived pain.
He also raises the question of whether or not these file actually do any good in terms of lowering inappropriate ED visits or helping addiction.

My points:
Everyone who cares about EM ethics should read this article. It raises many of the important issues. I would argue several things.
First, I suggest that such files are valuable because they save time and money. If I know a patient to be a habitual ED abuser I am less likely to unleash a barrage of medical testing all over him and the taxpayer?s wallet. A good study could be done to see if there really are any savings.
Second, these files put me at ease if I have suspicions about a patient. They provide another piece of info to complete the picture. The caveat for this is that I cannot allow myself to be unduly swayed by such info. Even the abusers eventually get really sick.
Third, I would say that creating a system such as the one described would make the file unusable. I am too busy to initiate a multidisciplinary task force every time I get a seeker in the ED.
Lastly I would say that the true import of these files lies not in the files themselves but in what they represent. EDs and ED staffs are more and more the victims of abusive patients and the turkey file is one way to fight back a little. There is more and more an unhealthy, adversarial relationship that is emerging in the ED. The turkey file is a fairly small issue in itself but it is the tip of the iceberg. The real problems are much more pernicious.

 

[paramed2premed]

... the turkey file is one way to fight back a little. There is more and more an unhealthy, adversarial relationship that is emerging in the ED.

How did I miss that article? I appreciate your thoughts on the possible abuses of the T-file. Sometimes it seems as though the nurses and medics are more excited about "catching a seeker" than in doing a thorough Hx&P. Example:

Nurse: "Aha, I thought I recognized that patient! His card says he's been in 10 times for back pain."

Me: "But he has a fever and can't stop vomiting..."

The above example is somewhat self-aggrandizing, but is actually true. I will not recount all the patients whom I advocated for, but left AMA after shouting "just give me some Percs!"

 

[Coleman]

Well put DocB

With PC term and HIPAA rules, we are slowly moving away from assessing any negative attribute whatsoever to patients. I am a huge patient advocate, but I also require the patient to be part of this team.

As an EP and the PMD for most of these patients, you have to run the gauntlet with them on r/o things that will kill them, but overall having these "turkey lists" is only a good thing. I look at them as a piece of their PMH. You know: DM, HTN, and frequent "back pain" that is only treated with Demerol.

 

[SHOX]

By the virtue of being the 24/7 safety net for and unraveling health care system we indeed bear the brunt of the political, economic and social impact. Why are these patients "mad"? A very complex question indeed...? These "Turkeys" are vulnerable psychiatrically and/ or physically (ie. untreated psych issues, drug dependence, chronic pain) and quickly fall throught the cracks of our high powered/ technalogically advanced medical system. We actively resuscitate 80 year olds with multiple co-morbidities in seemingly futile attempts at saving quantity, not quality, of life in a very resource intense fashion. This leaves little to no resources to allocate to the mentally ill or patients with substance addictions.

 

[docB]

Coleman put very well. These lists are useful as a part of the PMH. No more, no less.

Shox seems worried that turkey lists make it that much more likely that the underserved will be even more underserved. My response is to say that yes there are underserved people out there but the ED is not the appropriate place for them to start being served. I am not a PMD and I don't treat chronic conditions as well as a PMD (just as a PMD can't deal with acute exacerbations of chronic disease as well as I can). An inappropriate patient in the ED is an inappropriate patient even if they are underserved.

 

[SHOX]

You completely missed my point!

These "Turkey File" patients end up in the ED for a reason... I am merely pointing the finger at the dysfuntional health care system.

If we do not try and understand why these patients end up coming to us, then we will never be able to solve the problem.

I completely agree that many of these patients would be better served in an environment other than the ED.

SH

 

[paramed2premed]

Originally posted by docB
... An inappropriate patient in the ED is an inappropriate patient even if they are underserved.

Annals had a few articles last year on the conundrum of defining the "inappropriate patient." Turns out it's hard to do, at least consistently. For all the talk about our EDs being inundated with these resource-wasters, no one is sure how to describe them accurately.

Well, maybe the HMO's feel sure...

 

[docB]

We've drifted off of the discussion of the usual suspects in the turkey file, drug seekers. We're now onto the uninsured, underinsured, mentally ill, etc. We're now trying to use these people as a microcosm for the ill of healthcare in general. So, I'm going to make some generalizations so bear with me.

If we do not try and understand why these patients end up coming to us, then we will never be able to solve the problem.

I can tell you why many of these people come to the ER. It doesn't cost them anything and it's easier than going to the county clinic. I tell each and every one of them to go to county with these problems and they ask "Why should I?"

Annals had a few articles last year on the conundrum of defining the "inappropriate patient." Turns out it's hard to do, at least consistently. For all the talk about our EDs being inundated with these resource-wasters, no one is sure how to describe them accurately.

Yes, it's difficult to create a schema to describe each inappropriate patient. I would say it's like a supreme court justics and porn, I know it when I see it. Inappropriate patients include:
- anyone who when asked who thier PMD is says an ER doctor's name
- anyone who demands to be given meds rather than scripts because they don't have any money to fill scripts
- anyone who brings their kid to the ER for vaccines
- anyone coming to the ER for me to fill out their disability, work note or handicapped parking paperwork
...just to mention a few.
The goal is not to solve the healthcare crisis or to quantify and eliminate every resource waster but to try to limit the damage done by the worst of the worst.