TRAUMATIC AND NON-TRAUMATIC MORTALITY IN THE EMERGENCY DEPARTMENT

Background: The mortality rate in an emergency department is an efficient tool to appraise the quality of healthcare provided by this department. Objective: The main objective of this study was to estimate the mortality rate in the emergency department (ED) at King Faisal Medical Complex in Taif, Saudi Arabia, and to also determine the most common causes of death and the profiles of patients who die in the ED. Methods: This was a retrospective study conducted in (392,862) consecutive patients who were admitted to the ED during the period between June 1 st , 2016 and February 28 th , 2018 . Data were analyzed using SPSS 2012, version 21. Results: Out of 392,862 admitted patients, 194 (0.049%) died in the emergency room. The majority of these deaths were non-traumatic (88.1%). The most common causes of non-traumatic death were heart disease other than coronary artery disease (50.0%) and sudden death of unknown cause (33.0%). While traumatic deaths (11.9%) were predominantly caused by motor vehicle accidents (10.4%) and gun shoot wounds or falling down (1.5%).


Materials and Methods:-Study design:
This retrospective study was carried out in the ED of King Faisal Medical Complex (KFMC) in Taif, Saudi Arabia to estimate the mortality rate and identify the most common causes of death.

Data collection:
Data were collected from the medical records of 392,862 patients who were admitted to the ED of KFMC during the period between Jun 1 st , 2016 and February 28 th , 2018. Data regarding the patients' age, gender, cause of death, length of stay in the ED before death, and arrival status were extracted and recorded.
Patients who died after being registered in and admitted to the ED were included in the study, while patients who were not registered in the ED, and patients who died after being discharged from the ED were not included.

Statistical methodology:
Data were statistically described in terms of frequencies (number of cases) and valid percentages for categorical variables. Median and inter-quartile ranges (IQR) were used to describe non-parametric numerical variables. Comparison of categorical variables between the subgroups (cross-tabulation) was done using Chi-square tests, and the Mann-Whitney U test was used to compare non-parametric numerical variables between the subgroups. P values less than 0.05 were considered statistically significant. All statistical calculations were done using IBM SPSS (Statistical Package for the Social Science; IBM Corp, Armonk, NY, USA) release 21 on Microsoft Windows PC.

Ethical considerations:
We obtained the institutional review board's approval before conducting any study related procedures.

Mortality rate:
Per the collected data, a total of 392,862 patients were admitted to the ED throughout the study period. Of these patients, 194 (0.049%) died while in the ED.

Characteristics of patients who died in the ED:
The majority of patients who died in the ED were males (68.0%), while females constituted (32.0%) of the total cases. The median (IQR) age was 62.5 (±30.0) years with a range of 0-108.0 years old.

Length of stay in the ED before dying:
The median (IQR) length of stay was 101 (110) minutes with a range of 0-3,240 minutes. More details regarding the length of stay are provided in figure 1.

Causes of death:
The vast majority of patients (88.1%) died from non-traumatic causes, while 11.9% of the patients died from traumatic causes.

Causes of death among males and females:
The proportion of males who died due to traumatic causes (10.3%) was significantly higher (p=0.038) than the proportion of females who died from traumatic causes (1.6%).
More details about the causes of death among males and females are provided in table 1.

Age of patients who died due to traumatic and non-traumatic causes:
It was found that patients who died due to traumatic causes, with median (IQR) age of 32 (34.3) years, were significantly younger (p<0.001) than those who died due to non-traumatic causes with median (IQR) age of 65.0 (29) years.

Discussion:-
With a continuously growing population of patients that seek emergency medical care, along with the increasing number of visits to emergency departments (EDs) in several developed countries during the past decades, it becomes more important to give special consideration to the quality of service provided in the emergency department. Mortality rate is an efficient tool to assess the quality of medical services and healthcare provided to ED patients [18][19][20].
However, there is not enough information regarding the mortality rate in EDs in Saudi Arabian hospitals.
We conducted a retrospective study to obtain more information about the mortality rate in the ED of King Faisal Medical Complex, along with identifying the most common causes of death among males and females.
We reviewed the medical records of all patients who were admitted to the ED of King Faisal Medical Complex between June 1 st , 2016 and February 28 th , 2018, which constituted a total of 392,862 patients. We extracted data of patients who died while in the emergency room (194 patients) revealing a mortality rate of 0.049% in all admitted patients. This rate is relatively low compared to other rates reported in the literature, which ranged from 0.3% to 10.9% in some regions. These data indicate high quality of medical care provided in this department [11,12,21,22].
Most of the patient deaths (88.1%) were caused by non-traumatic incidents that included heart diseases (50.0%), sudden death of uncertain cause (33.0%), chronic obstructive lung disease (2.6%), pneumonia (1.0%), cancer (0.5%), coronary artery disease (0.5%) and toxicity (0.5%). This is consistent with a recent study published in 2017, which reported that cardiovascular diseases are the leading cause of death in the emergency department, and is also consistent with our findings that reveal more than half of the patients died from heart diseases [23]. Moreover, a 9year follow-up study of emergency room users reported that the most dominant causes of death include circulatory system disorders, cancer, and violent events [24].
Regarding deaths due to traumatic causes, which was reported in 10.3% of deceased patients in our study, motor vehicle accidents constituted 10.4% of these deaths and gunshot wounds or falling down constituted (1.5%).