Epidemiological Study of Mortality in the First Twenty-Four Hours of Emergency Admission

Introduction: Epidemiological investigation of Mortality is essential for health policy control of risk factors and disease. Obtaining this information is the essential basis for planning, management and evaluation, and accountability in countries' health sector. Studying Mortality and its etiologic factors are the most appropriate strategies to reduce Mortality. Objective: The study aimed to investigate the causes of death and prognostic factor of death in patients referred to the emergency department. Method: this was a cross-sectional study from 2016 to 2018 at Tohid Teaching Hospital in Sanandaj. All history and clinical examination data and Para clinical study of the patients who had expired in the first 24 hours after emergency department admission were collected in questionnaire sheets. The data was interred into spss software and analyzed using descriptive statistics frequency and percentage. Result: 73 patients, 43.8% female, and 41% male with a mean age of 63.6 years old 20-90 evaluated in our study. The first common chief complaint of the patients was chest pain 24.7%, and the most common past medical disease in the patients was hypertension 28.8% also the first common reason of death was ischemic heart disease 31.5%.43.8% of patients had abnormal electrocardiograms, 19.2% had dysrhythmias, and 24.6% had ischemic changes. Laboratory results also showed that the prevalence of sodium imbalance was 53.5%, and potassium and calcium imbalance were 37.9%& 80.8%. Also, 80.8% of patients had PH abnormalities, 30.1% acidosis, and 50.7% alkalosis. Conclusion: According to the results, it can be concluded that patients with cardiac problems or a history of cardiovascular disease are the highest risk patients and should be considered more serious. Also, electrolyte and blood gas imbalance were prevalent in these patients.


Introduction
Death resulted from the cessation of the body organs function [1] and may occur when patients have severe illness that is hard to be stabilized, and the Emergency Department ED care may not be sufficient [2].
The raw mortality rate varies based on epidemiology, type of hospital, and social conditions; for example, the raw mortality rate in 2018 was 5.3% in Iran, 9.4% in France, 11.8% in Germany, 7.3% in India, and 10.5 in Italy [3,4]. Many of this death occurs in the emergency department of hospitals. Factors like Intubation, low systolic blood pressure on presentation, increased age, and comorbidity can increase emergency department mortality rate, an epidemiologic study in Tehran, Iran, resulted in the mortality rate of patients who referred to the emergency department was 0.9% and the mortality rate in UMHAT -Pleven emergency department was 2.4/100000 [4][5][6].
Many studies have evaluated the most common causes of mortality in the emergency department; many recent studies showed Cardiovascular diseases like myocardial infarction, Pulmonary embolism, severe traumas, and cerebrovascular accidents, and Oncological Pathology Were the common causes of death in the Emergency Department [6][7][8]. Also, a lab index like serum venous lactate level in Patients with Infection can predict mortality rate in the emergency department [9]. This descriptive-cross sectional study has been created to check epidemiological factors of mortality rate in admitted patients in the emergency department of Tohid hospital in Sanandaj and make decisions and improve facilities to reduce the mortality rate of the patients.

Study Design and Period
This cross-sectional study was performed on all patients who died at Tohid emergency department hospital in Sanandaj from 2016 to 2018.

Study Area
This cross-sectional study was performed on all of the patients who died at Tohid emergency department hospital in Sanandaj from 2016 to 2018.

Inclusion Criteria
Inclusion criteria included all of the patients who died within the first 24 hours of hospitalization.

Exclusion Criteria
Exclusion criteria included patients who died with an incomplete document of hospitalization.

Data Collection
The records of all patients died in the first 24 hours after admission at Tohid Hospital in Sanandaj from 2016 to 2018 was collected and evaluated, Data collected by an emergency doctor using a pre-tested data collection form.
Patient information includes ECG, Primary Oxygen Saturation, Patient Clinical symptoms, Vital signs on Arrival, consciousness level upon Arrival to the Emergency Department, Primary Patient Tests Including CBC diff, Na, K, Ca, Cr, ABG entered the relevant questionnaire sheet. The cause of death recorded and The data entered into SPSS statistical software and descriptive statistics for quantitative variables with central and dispersion indices and qualitative variables with frequency and percentage. Chi-square and Fisher exact tests performed.

Result
In this study 73 patients, 43.8% female and 41% male with a mean age of 63.6 years old 20-90 was evaluated [table 1]. First common chief complaint of the patients was chest pain with 24.7%, the second ones were dyspnea 15.1%, and weakness 15.1% and the third most common was decreased level of consciousness with the prevalence of 11%; also the least common chief complaint of patients was alcohol abuse, burning, and gunshot [table 2].
The first common reason of death was ischemic heart disease 31.5%, and renal failure 11% and the least common was pulmonary thromboembolic 1.4%. The cause of death was undiagnosed in 1.4% of patients [table 3].
Among the patients who died in Tohid hospital ED 64.4% had a past medical history for a known disease; That the most common was HTN 28.8% and the second most common was diabetes mellitus type 2 19.2% and also the least common was congestive heart failure and gastrointestinal bleeding and chronic obstructive pulmonary disease and chronic renal disease [table 4].
At the initial physical examination, 8.2% had low, and 37% had a high heart rate, 43.8% of patients had abnormal electrocardiograms 19.2% had dysrhythmias, and 24.6% had ischemic changes. Also, 4.1% had low, and 74% had a high respiratory rate.
Also, the electrolytic imbalance was common in patients; for example, sodium imbalance prevalence was 53.5%, potassium and calcium imbalance was 37.9%, & 80.8%. Also, 80.8% had PH abnormalities 30.1% acidosis and 50.7% alkalosis, and 67.1% of patients had a high Cr level for age and gender [

Discussion
According to our study results, it can be concluded that the mortality in patients referring to the emergency department with patients with cardiac complaints, chest pain, or history of cardiovascular disease hypertension is higher than others, so it should be considered more dangerous. Alimohammadi [8] at al; showed that patients referring to ED with cardiovascular complaints have a higher mortality rate higher versus. Also, in the study of Vanbrabant [10] et al.; the mean cause of mortality at the emergency department was cardiac, and in the study of Stefanovski et al. [6], acute myocardial infarction was the leading cause of mortality in the emergency department.
Cannon et al. [11] found that the essential action in patients with cardiac symptoms, especially in patients with myocardial infarction, in the early management of these patients in the emergency room because most deaths due to myocardial infarction occur within the first few hours after the onset of symptoms.
Patrick J. Shao et al. illustrated that morbidity and mortality in patients could be affected by the hypertensive crisis; they showed that the mortality rate in patients with emergency and urgency hypertension was 26.8 and 3.1% [12].
In Taiwan, a retrospective study performed on patients who died within the first 24 hours after emergency after admission; from 210 cases that were involved in this study, 25.8% were preventable deaths, and the causes of them included inappropriate medical management, delayed diagnosis, and misdiagnosis [13]. Also, our results showed that electrolyte and blood gas imbalance were prevalent in these patients. According to the study of Balcı et al., hyponatremia is the most common electrolyte imbalance, and the least common was hypomagnesemia in the emergency department [14].
Tazmini et al. [15]. Illustrated that electrolytic imbalances like hyponatremia, hypokalemia, hypercalcemia can increase mortality in hospitals [15]. Also, Hypernatremia and acidosis can increase mortality rates in traumatic brain injury patients in the first 24 hours [16]. On the other hand, Jiachang et al. explained that hypo and hyperuricemia, acidosis, Hypernatremia, and AKI during hospitalization increase the hospital mortality rate [17].
Dyspnea, fever, and systemic deterioration are the most common symptoms, and confusion, edema, and rales are the most common sign in patients with electrolyte imbalance, and tachycardia is the most frequent pathological findings their ECG 15, so in patients with these sign and symptoms we should consider electrolyte imbalance, and we recommend to check electrolytes.

Conclusion
According to the results, it can be concluded that patients with cardiac problems or a history of cardiovascular disease are the highest risk patients and should be considered more serious. Also, electrolyte and blood gas imbalance were prevalent in these patients. So we recommend checking atrial blood gas and serum electrolytes in patients who refer to the emergency department and paying more attention to the patients with cardiovascular complaints to reduce patient mortality in emergency departments by controlling these factors.

Ethics Approval and Consent to Participate
This manuscript has been ethical approved by the ethics committee of Kurdistan University of Medical Sciences, Sanandaj, Iran.