Journalwatch: Emergency dept “frequent flyers” not hypochondriacs, says new study

eMJA logoY’all know that one of the science-reporting peeves is the media not providing enough information for readers to find the original source without detective work. There’s often a last name, and sometimes a journal name, but publication dates are uncommon, and article titles are never shown. How hard is it to throw in a reference, people? Especially on your web publication?

Science reporting has had a new airhead moment, with ABC News reporting a new study as coming from “the Australian Medical Journal (AMJ)”.

“What is this little tinpot journal is this that I’ve never heard of?,” I thought. “And why is Jelinek publishing in it?”

But no. It doesn’t exist. We only have one general medical journal to speak of, so how hard is it? MJA. Medical Journal of Australia. If you google “Australian Medical Journal”, the MJA is the first hit. It’s at If you google “journal australia” (no quotes), it’s the first hit. If you google “medical australia” (no quotes), it’s the first hit. (YMMV, if you’re googling from an overseas IP.)

Anyhow. Everyone has a bad day. But if the news media would introduce a policy of some sort of referencing, mistakes like this would be less likely to obscure their sources.

Jelinek’s article is here:
Frequent attenders at emergency departments: a linked-data population study of adult patients.
(George A Jelinek, Moyez Jiwa, Nicholas P Gibson and Ann-Maree Lynch, 2008; 189 (10): 552-556.[Registration required for full article])

“Frequent Flyers” at EDs have significant healthcare needs

emergency department at a hospitalFrequent attenders at emergency departments, sometimes dubbed “frequent flyers”, are often derided as hypochondriacs, as misusers of the ED, as people with nothing seriously wrong, who just want attention and refuse to use the medical system appropriately.

This was a linked-data study of all adults attending an ED in Perth over a six and a half year period. Contrary to another popular belief of women being excessive users of medical care, men predominated the statistics at every level, from 52% among NFAs (non-frequent attenders) to 71.2% among FAs (frequent attenders) attending more than 40 times a year. Frequent attendance also increased with age.

The key finding was that the largest categories of frequent attenders, those who attended from 5-20 times (moderately frequent attenders or MFAs), were far from being “whiners” with a high level of inappropriate presentations. They weren’t seeking help for trivial injuries, tension headaches, and grass stains. They were over-represented in the three highest-urgency triage categories, and were also over-represented in admission statistics.

Moderately frequent attenders had higher rates of diagnoses relating to unstable angina or injury, and very frequent attenders had higher rates of psychiatric illness, self-harm, and intoxication. Very frequent attenders had a much higher incidence of self-discharge or leaving before assessment, which is a particularly worrying statistic. Fewer than 20% of EFAs (40+ visits) were triaged to “non-urgent”, yet in 21% of total EFA attendances, the person left without assessment or discharged themself at their own risk.

Discharge at own risk

At least some of these self-discharges would have been in the “semi-urgent” triage category (category 4), those who have been determined to have a potentially serious problem that needs assessment within an hour; and quite possibly there were some in higher categories. Examples of problems that might be triaged to “semi-urgent” include bone fractures that do not threaten life or limb; accidental or deliberate wounds that haven’t severed a major nerve or artery but need treatment; migraines; a hot swollen joint; and psychiatric presentations where there is a semi-urgent need for assessment/treatment, but where the person not an obvious immediate risk to self or others and can stay under observation for up to an hour before treatment.

Previous statistics have shown that the death rate in the following month for patients categorised DNW (Did Not Wait) is 0.14% – about three times the death rate in the entire population – yet people who DNW are likely to young adults. DNWs have a lower mortality than those who are admitted to hospital, but clearly still have a significantly higher mortality than the general population, so loss to follow-up is a problem.

Will better community mental healthcare fix this?

Better healthcare solutions for people with chronic psychiatric illness and addiction are sorely needed, but the best community mental healthcare is never going to reduce the need for emergency psychiatric care to zero. In the meantime, people with serious mental illness are just as sick and just as in need of emergency care as people with coronary artery disease and appendicitis and broken legs. Attitudes that begrudge people emergency medical care based on their diagnosis category – that see people with mental illness as “less deserving” – have no place in Australia’s healthcare system.

Jelinek et al sum up:

Representing 97.4% of FAs at Perth EDs, MFAs are an important cohort of emergency patients with particularly serious and urgent problems, often needing inpatient care. MFAs appeared to be sicker and more in need of care than the average ED patient and the few EFAs.

It may be from EFAs that a common misconception has arisen about FAs being time-consuming “illegitimate” users of ED resources. In fact, the great majority of FAs were sicker than other patients and more often required inpatient management. However, the total number of FAs comprised only a small percentage of ED patients, and the workload associated with their attendances was relatively inconsequential compared with the overall work of EDs.

Although EFAs had less urgent conditions and required admission less often, it should not be assumed that these patients are more suited to management in general practice, as their admission rate is still many times greater than that seen from general practice, and nearly half arrive by ambulance. A single hospital study in Melbourne has previously noted that attempting to divert the most frequent ED attenders to general practice may not be successful because of the severity, acuity and casemix of their presentations.

See also Fulde & Duffy’s “Emergency department frequent flyers: unnecessary load or a lifeline?” (MJA 2006; 184 (12): 595).

access block. patients on corridor trolleys Access block and overcrowding

Emergency department overcrowding is a major problem in Australia, and it is damaging people. Overcrowding clearly puts patients at risk, both by delayed treatment and by issues with emergency evacuation. It is dangerous for workers, who are exposed to high levels of workplace stress, and an increased risk of violence. Ambulance staff and users are feeling the pressure also, with an increase in “ramping” time of almost 750 percent in the past year in Western Australia. “Ramping” is when paramedics must continue to care for a sick or injured person in the ED ramp area, when hospital staff are unable to take over.

However, access block is not being caused by frequent attenders, nor is it being caused by low-acuity presentations.

Access block is being caused by the flaw of averages, the failure to provide enough beds in acute hospitals, and by the shortage of residential aged care in Australia. Beds in the hospital are full of acutely ill people and people “awaiting placement”, causing a bed-block situation: acute emergency department admissions languishing in the ED, in holding wards, in corridors – at the time they need help and comfort the most.

Categories: health, medicine

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7 replies

  1. How bad does the situation have to get before the govt. will fund more beds in hospitals and more aged care places. I sometimes think that if I won Lotto I would open a retirement village and a nursing home. Pay the staff well, and you’d have no trouble staffing them. Show them how it should be done.
    Also, not surprising that most people turning up at the emergency dept are in need of care. No one goes to sit in one of those for hours for the fun of it.

  2. It doesn’t surprise me that men are more likely to show up at the emergency department – in my retail pharmacy experience, women are more likely to seek treatment early, for themselves and their children. Men are more likely to refuse to “waste time” going to the doctor/taking medications/seeking follow-up care, so they end up seriously ill and need emergency care.

  3. One thing which always amazes me is that the one thing which apparently isn’t affected by the laws of supply and demand are the wages of hospital staff (particularly nursing staff). According to said laws, if the supply of something is restricted (which is becoming the case, as more and more young people decide not to be “called” to the nursing profession, and instead decide to do more straightforwardly rewarding careers – like busking, for example) then the price for it goes up. Yet whenever nurses ask for a payrise, the overall media and governmental response implies they’ve also asked for an individual weekly bath in the blood of the first-born male offspring of each and every taxpayer.
    I suspect part of this attitude (along with a similar attitude toward teachers) is because nursing was, and to some extent still is, seen as a primarily “feminine” profession. It was a “calling” or a “vocation”, something a middle-class young woman might do in the years between leaving school and getting married and settling down. The money was therefore pocket money, because after all, it wasn’t a “career”, like medicine. If a woman did choose to make nursing her full-time occupation, it was seen in the same light as entering a nunnery (to which it was often equivalent).
    These days, nursing is a profession which requires a tertiary education, and incurs a HECS/HELP debt – and then asks for the same sorts of long hours my mother used to do in the old “apprenticeship” system, and grants the same sort of low pay. It therefore isn’t surprising a lot of young people are effectively deciding to turn away from nursing as an option, and go into something which is more likely to earn them enough to pay both the HECS/HELP debt and the mortgage.
    Meg Thornton’s last blog post..Fic: In Memoriam

  4. Too right, Meg Thornton!

  5. People in my rural area (large town of 12,000+ and outlying areas) go to the ER a lot of the time simply because they cannot get into see a doctor anywhere else for at least a week, often longer. Today for example, I tried to get into see a GP. I attend two clinics on a “regular” basis. Neither could get me in until next week with ANY doctor (so I wasn’t being picky about who I wanted to see). I rang every other clinic in town and was told they were either booked out or weren’t taking on new patients. Even the old methods of ringing first thing in the morning to get squeezed in for an appt, don’t work anymore. So now I have to decide if I tough it out or if I go to the ER for what really isn’t an emergency but more likely a middle ear infection that is driving me insane. The fact I have already been to the ER at least 4 times this year doesn’t help (twice for gastro, twice for gall bladder attack). I don’t want to be classified as one of those ‘whiners’ but what do you do when you can’t get in to see a doctor anywhere else?

  6. My belief is if you are in pain, you deserve treatment. Inner ear infections are damn nasty so go to the ER and get something for it. I doubt you will be the only one who can’t get a Dr’s appointment turning up there.


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