IJCS | Volume 32, Nº6, November / December 2019

608 Leite et al. Accreditation in outcomes of patients with ACS Int J Cardiovasc Sci. 2019;32(6):607-614 Original Article research and patient care service 6 . In Brazil, we have the National Accreditation Organization (ONA) that follows the standards established by the Ministry of Health 1 , where the institution is evaluated and receives a classification ranging from level 1 to 3, which represents accreditation with excellence. 3,11 Several studies have analyzed the positive effects of the process and have found that there was a reduction in the length of hospital stay, improved management of preventable outcomes, reduction of hospital mortality, and it helps to create internal protocols. 12-15 Coronary artery disease (CAD) is the most frequent cause of death in the world, consisting of approximately 13% of all causes of mortality. 16,17 Acute coronary syndrome (ACS) in Brazil represents an important cause of hospitalization and acute myocardial infarction is the second leading cause of death in the country. 18,19 These data demonstrate the importance of adequate management of ACS, especially with regards to the creation of guidelines. 20 The length of stay in both the Intensive Care Unit and at the hospital is an important parameter of quality and better prognosis for the patient, where a decrease of this time is related to reduced hospital costs with the patient and a lower rate of complications, such as lower readmission rates, death or infection (such as mechanical ventilation-related pneumonia, central venous catheter infection or urinary tract infection related to bladder catheter use). 21 In a reference Cardiology hospital in Salvador, Bahia, ACS was considered the main line of care in the ONA 3 accreditation process, held in December 2015. The primary outcome of this studywas the comparison between length of stay at the Coronary Care Unit and hospital stay of patients with ACS before and after ONA 3 accreditation. Secondly, the impact of accreditation on clinical outcomes was analyzed. Methods Study design and population This is a prospective observational registry that consecutively included patients diagnosed with Acute Coronary Syndrome hospitalized at the Coronary Care Unit (CCU) of Hospital Santa Izabel (HSI) — Salvador/ BA from February 2015 to August 2016. Santa Casa de Misericórdia da Bahia — HSI is a tertiary philanthropic hospital that underwent ONA 3 accreditation (excellence) in December 2015 and successfully achieved this goal. The study population was divided into two groups: Period 1 (Pre-accreditation: before December 1, 2015) and Period 2 (Post-accreditation: as of December 1, 2015). All patients with diagnostic confirmation of acute coronary syndrome (including unstable angina, ST- segment elevation acute myocardial infarction — STEMI — and non-ST-segment elevation acute myocardial infarction—non-STEMI)met the inclusion criteria, aswell as patients receiving drug and/or interventional treatment for acute coronary syndrome at Hospital Santa Izabel. Patients readmitted after elective interventional treatment of previous acute coronary syndrome were excluded. The data were collected prospectively through a structured electronic medical record of the coronary care unit by a team specifically involved in the collection, completed by the unit’s attending physician, always with the possibility of rediscussing some topic with the physician. In summary, the variables include socio-demographic and clinical aspects, in addition to admission, evolution and outcomes. Statistical analysis A descriptive analysis of the frequencies of variables was performed using IBM SPSS Statistics 14.0. Initially, the Kolmogorov-Smirnov test of normality was performed to find out whether the variables had a normal or non-normal distribution pattern and, from this, the statistical tests and the most adequate description of each variable were defined. The variables were described using measures of central tendency (mean, median) and dispersion (standard deviation, interquartile range) when continuous and by absolute and relative frequencies, for the categorical variables. Comparisons of clinical outcomes between the pre- and post-accreditation periods were performed using the chi-square test (X²) or Fisher’s exact test when the sample number was < 5. The Mann-Whitney test was used to compare the time of hospitalization at the coronary care unit and hospital admission between the two periods, since non-parametric variables were involved. In addition, multivariate analysis was performed by multiple linear regression to find out where the hospital accreditation process was an independent predictor of length of hospital stay and length of stay at the CCU, controlling for relevant confounding factors in the