Magnitude, cause, and factors associated with early mortality in the adult 1 emergency department of Tikur Anbesa Specialized Tertiary Hospital, 2 Ethiopia: a two years retrospective chart review

Background: Adult emergency department mortality remains high in resource-limited lower- 27 income countries. The majority of deaths occur within the first 72 hours of admission to the 28 emergency department which is termed as early emergency department mortality. Many of 29 these mortality’s can be alleviated with appropriate intervention. Though the magnitude, 30 cause, and the time interval of death after their admission to the department have a huge 31 aspect for the clinical world, however, studies on this topic lack adequate data. Therefore, this 32 study was aimed to assess the magnitude, cause, and factors related to early mortality in 33 patients presented to the emergency department of Tikure Anbesa Specialized Tertiary 34 Hospital, Ethiopia from March 2018 to 2020. 35 Methods : A retrospective cross-sectional study design was conducted to address the study 36 objectives. Retrospective data were collected from the patients’ records who died in the 37 emergency department from March 2018 to 2020. Data entered using Epi data 4.2.1 and 38 analyzed using SPSS Version 23. Using the Chi-square test, binary and multiple logistic 39 regression analyses were carried out to measure the association of variables of interest and 40 the outcome variable (early emergency mortality). P-value < 0.05, odds ratio with 95% CI 41 were used to identify the significant factors. 42 Results : From the total identified emergency department death records, 506 (59.8) were early 43 mortality. Triage category red AOR 0.23 95% CI 0.1-0.55, co-morbid disease HIV AIDS 44 AOR 2.72 95% CI 1.01-7.30, residence Addis Ababa 2.78 (1.36-5.68) and Oromia 3.23 95% 45 CI 1.58-6.54 and duration of illness 4-24 hour AOR 0.47 95% CI 0.26-0.87 were found 46 significantly associated with early emergency department mortality. 47 Conclusions and recommendations: The magnitude of early mortality was significant. 48 Residence Addis Ababa and Oromia, triage category red, co-morbid disease HIV AIDS, and duration of symptom 4-24 hours were significantly associated with early emergency department mortality. Early detection and intervention are required to minimize emergency mortality.


Introduction
Emergency Department (ED) is a multifunctional unit at which patients are guaranteed access 56 to 24/7 emergency health care service at any level of a health facility. The department is the 57 backbone of the health facilities and the general public by providing the first line of care on 58 arrival. In short, ED is the "shop window" of the health service [1]. In providing emergency 59 care, death can be one outcome, it can be early or late death. Early mortality is defined as the 60 death of a person within 72 hours of ED presentation [2]. Whereas, very early ED mortality is 61 defined as death within 24 hours of admission to ED [3]. 62 Emergency department mortality has a profound impact on the individual, society, and 63 the entire health system. It is becoming one of the leading causes of death in hospitals. 64 Globally, it contributes to 15-16% of all mortalities in hospitals. The value is much higher in 65 Low and Middle-Income Countries (LMICs). In Sub-Saharan Africa, especially in central, 66 east, and west, it is 5.1% higher than in higher-income countries [4,5]. 67 In recent years, a significant proportion of the burden of disease and patient mortality is 68 aggravated in ED [6,7]. The major causes of this mortality are cardiovascular disease, traffic 69 accidents, trauma, and cancer. Even if, the etiologies differ in various geographical locations, 70 it has been reported that these causes cover 15-60% of all the mortalities [8,9]. Decades of 71 advances in clinical science and care delivery have dramatically improved patient outcomes 72 for a range of acute conditions, in higher-income countries. Clinical interventions like 73 standardized ED trauma protocols have been previously shown to decrease mortality in high 74 and few middle-income countries [9]. Moreover, the severity of injury or illness can be the 75 cause of death on its own. The care and management at the hospital also determine the fate of 76 the patients' life or death, so do lack of, or inadequacy of medical installation and the staffs, 77 thereof inaccessibility of transportation due to the topography of patients' residency and 78 unsuitable (or unavailable) road network delays arrival of the patients to the hospital, lack of rapid transfers of the patient to other departments (for definitive treatment) which aggravate 80 illnesses or injuries and could cause death also increases the ED burden. These and other pre-   regression was used to test for the association between each variable with the dependent 148 variable (early ED mortality). Bivariate logistic regression with a crude odds ratio p-value < 149 0.2 and multivariate logistic regression with adjusted odds ratios were conducted for excluding potential confounding factors between the variables. P-value < 0.05 was 151 considered statistically significant. The odds ratio with a 95% confidence interval was 152 analyzed to verify the strength of association.

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The cause of ED mortality was listed out and then merged into traumatic and non-154 traumatic causes.

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Over the two years study period a total of 30086 adult patients visited the ED; 846 (2.8%) 173 death was registered. Of these 65 (7.68%) dead on arrival, 177 (20.9%) dead after 72 hours 174 and 604 (71.39%) deaths occurred within 72 hours after arrival alive to ED. 506(59.8%) 175 charts qualified the criteria for analysis, the remaining 98 (11.6%) charts were excluded 176 because of incomplete records.     Strength and limitation of the study 309 The primary strength of this research is it's a two years retrospective study and all qualified 310 data were included. This highly increases the quality of representativeness. In addition, the 311 finding provides baseline statistical data for ED mortality in TASTH and Ethiopian hospitals 312 as a whole. The analysis of predictors of early ED mortality offers essential information for 313 the development of health policy and intervention to minimize early ED mortality.

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Since the study is a retrospective chart review, triage records were at times incomplete 315 concerning the leading cause of death. Another limitation of this study was missed charts 316 which potentially limit the result. This study was limited to the collection and analysis of data 317 contained in HMIS data in TATSH.

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This study has found that generally, early ED mortality in TASTH is substantial. The 320 mortality load of a road traffic accident and respiratory disease in the TASTH is high, and the 321 early ED mortality rate is higher among males than females. The majority of patients with 322 respiratory disease die within 24 hours of admission to ED. As EM increase in Ethiopia, the 323 possible impact of interventions intended at minimizing mortality among clients with co-morbid illness, who reside in the Addis Ababa and Oromia region should be encouraged.

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Emphasizing on the duration of symptom and triage category is also an additional point.