The older the people are, the more likely they die of short-term mortality. Therefore, more care should be taken of the elderly. Compared to younger individuals, the elderly patients are at more risk of adverse outcomes, and they should be paid more attention in the emergency department when a risk assessment is performed. A study by Schultz et al. (2019) demonstrated that 139 middle-aged patients and 596 elderly ones died in 7 days. A 7-day mortality rate in the elderly was proved to be higher(12). A study by Nørgaard Bech et al. suggested that old age was an important risk factor for short-term mortality(5). The research by Gentile et al. to identify the risk factors for short-term mortality among the elderly three months after presenting to the emergency department revealed that there were two independent predictors of mortality: malnutrition and the score scale of the cumulative disease for the elderly. Malnutrition was found to be the strongest independent risk factor for short-term mortality(13). This study was conducted in line with the present research. More special care for the elderly seems necessary because of their increased chance of mortality.
Studies have also demonstrated that abnormal vital parameters and the severity of the disease on admission in the first hours and days are associated with mortality (5, 11). A study by Bruun Kristensen et al. (2015) indicated that a seven-day mortality rate varied for1.8% of emergency department patients, 2.2% of ambulance patients, and 5.7% of emergency care unit patients. The best blood pressure was 95 to 119 mm Hg in the emergency department, 103 to 120 mm Hg in the ambulance and 101 to 115 mm Hg in the emergency care unit. Systolic blood pressure does not solely suffice to identify high-risk patients. However, if the threshold is determined, the systolic blood pressure threshold of 100 to 110 mm Hg is probably more suitable than 90 mg Hg(3). Also, the higher or lower the respiratory rate, the higher the risk of short-term mortality.
In the present study, the variable of body temperature in the normal range was found to have a significant impact on short-term mortality. However, a study by Nørgaard Bech et al. indicated that body temperature was not found to be associated with short-term mortality when the patient was admitted to the emergency unit(5). This might have been due to the specific characteristics of patients that requires more investigation.
A significant relationship was found between the duration of the patients' stay at the hospital and their short-term mortality. Furthermore, as the duration of the patients' stay at the hospital increased, the chance of patients’ death decreased by 0.5%. Because the hospital provides better care for the patient, it is suggested that patients stay at the hospital until they recuperate completely.
The time the patients arrive in the hospital's emergency department in terms of days of the week did not have any statistically significant relationship with short-term mortality. There was a close relationship between the patients' arrival time in the hospital emergency department in terms of working hours and premature death. Increasing a class to a working shift increases the probability of death by 18%. A rise in the probability of morality may be due to the fact that in the evening and night shifts, the official in charge of the emergency unit is not present.
However, the study by Nørgaard Bech et al. suggested that the severity of the disease by the time the patient is admitted, transfer by the emergency physician and abnormal vital parameters were associated with a 0-2 rate of mortality(5).
A study entitled "Causes of death in the emergency department; a short report" was conducted by Alaei et al. in Iran in 2014. The most prevalent causes of death were respiratory disease, heart disease and trauma. Respiratory, cardiovascular and trauma diseases are the most common causes of death in the emergency department, so proper planning, training of staff and provision of advanced equipment for emergency departments can be very effective in reducing the number of deaths(14). Comorbidity is also one of the causes of short-term mortality. Therefore, an exact background must be taken from the person at the time s/he is admitted.
In the present study, there was no statistically significant relationship between short-term mortality and the time the patient was admitted to the hospital in terms of working shifts in any of the time intervals. It is rational to suggest that the personnel's working shifts are not associated with death rates. The results by Guttman et al. suggested that the risk of complications had increased with the mean duration of stay, and the proportion of short-term mortality had increased by the same ratio. Patients who had been discharged from the emergency department earlier were not exposed to short-term complications(15).
Short-term mortality was significantly related with an increase in one unit based on CCI (Charlson Comorbidity Index). Thus, as one unit is added to the patient's CCI score, the chance of death increases by 3.8 times. Comorbidity is also one of the causes of short-term mortality. Therefore, an exact background must be taken from the person at the time s/he is admitted. Results of a study by Esteban et al. proved that the lowest mortality was associated with basal dyspnea. The highest mortality rate was associated with basal dyspnea, use of assistive devices, dysfunctional respiration by the time of arrival at the emergency room, with Glasgow score being less than 15 (16). Many studies suggested that the way the patient was transferred to the hospital(17) and the first-time visit of patients by the physician in the hospital emergency department were associated with the outcome of the patients' fate in the pre-hospital emergency department(18-20).
Short-term mortality occurs in many Iranian hospitals and it is because of various factors including the patient him/herself, the healthcare team, and the health system. Improving the professional knowledge and nurses' and physicians' skills in the emergency departments at hospitals and pre-hospitals, as well as strengthening and reviewing emergency guidelines, can help reduce the mortality rates. Of course, there may be other hidden issues; however, health-policy makers and directors should consider programs to help improve the hospital and pre-hospital services which aim at reducing the patients’ deaths.
That the way the patients arrives at the hospital is significantly related to the patients' short-term mortality (Sig = 0.00) is to their benefit as it may help prevent such death rates. This suggests that patients who had been taken to the hospital were in a better condition than those who had presented to Nemazi Hospital on their own accord(17).
This study investigated the risk factors associated with short-term mortality in Shiraz Nemazi Hospital. Various factors were found to have affected the short-term mortality. Hospital and emergency department managers must consider various factors, including patient-related factors, emergency department, and the pre-hospital and hospital emergency system in order to reduce the short-term mortality. The following suggestions are provided in line with the present study:
- It is suggested that special training courses should be held to prepare emergency department personnel to improve their performance so that short-term mortality is reduced.
- It is suggested that guidelines and instructions should be provided for sensitive and vulnerable groups.
- It is advised that needs assessment should be done to equip the hospitals' emergency department and pre-hospitals services for rapid response to patients.
- It is recommended that a committee should be established to investigate short-term mortality at hospitals and medical universities of the country.
That the study only incorporated one hospital was a limitation. The findings at other hospitals in Fars province or different provinces of Iran may be different from the finding of Nemazi Hospital.