IJCS | Volume 32, Nº6, November / December 2019

612 Leite et al. Accreditation in outcomes of patients with ACS Int J Cardiovasc Sci. 2019;32(6):607-614 Original Article hospital stay. Patients with ST-segment elevation also had a reduced length of hospital stay, but this data did not present any statistical significance. In a multicenter study conducted by Sack et al. 24 in 73 hospitals, the quality of care offered and the patient’s satisfaction with their hospitalization in accredited and non-accredited hospitals were analyzed. 24 The population considered was more comprehensive, excluding only obstetric patients and pediatric patients. As a result, it was found that the median length of hospital stay in accredited hospitals tended to be lower, but with no statistical relevance. 24 In the sample of this study, the population was more specific, and the reduction in hospital length of stay may be associated with a better systematization of care for these patients, which was confirmed in this study through a multivariate linear regression. Furthermore, it can be assumed that, with improved care, with protocols established and fulfilled, the patient presents more favorable conditions for early discharge. Also, regarding the length of stay, a study conducted by Falstie-Jensen et al. 9 also found that patients hospitalized in accredited hospitals had a shorter hospital stay, 9 which is consistent with this study. Regarding the outcomes analyzed, in the current study, it can be seen that the tendency related to cardiogenic shock was a reduction in the sample studied and an increase in patients with STEMI. Regarding mortality, there was a decrease in this variable both in the sample as a whole and in patients with non-ST- segment elevation, but without statistical significance. In the analysis of subgroups, there was an increase in the number of deaths in patients with ST-segment elevation. Compared to the Eagle 15 study, it can be seen that the patients analyzed in the United States showed an increase in the number of cases of cardiogenic shock and that mortality decreased significantly. 15 One possibility to be raised to increase the number of deaths of patients with STEMI is that there were more admissions of more severe patients in the second period analyzed. According to Greenfield et al. 14 by undergoing a quality assessment such as the hospital accreditation process, the institution tends to receive more patients with more serious disorders 14 , possibly due to the recognition of the effectiveness of the service offered. Another issue to be emphasized is that the results on mortality obtained in this analysis should be interpreted carefully. In a study conducted byWilliams et al. 25 in 2005, a dissociationwas found between the variable in-hospital mortality of patients with acutemyocardial infarction and the other variables analyzed. These other variables were more associated with the quality of the service offered to the patient, and an improvement was perceived after the hospital evaluation process. The authors pointed out that previous studies reported a lower sensitivity of the clinical outcomes to the detriment of quality parameters with regard to the protocols established at the hospital. 25 In-hospital mortality refers to themanagement of a specific patient and does not necessarily shows the ineffective outcome of all other procedures of care provided during hospitalization. 25 Due to this, the number of deaths is not considered a good parameter in assessing the impact of the accreditation process. Regarding the other variables of clinical outcomes, there was an increase in reinfarction and CRA, especially in patients with ST-segment elevation, but without significance. In 2015, Falstie-Jensen et al. 9 studied the relationship between accredited hospitals and acute readmission (up to 30 days), considering all patients admitted to the hospital, and it was found that patients seen in institutions certified as accredited institutions did not present any difference comparing with non- accredited hospitals. 9 Given that reinfarction can be considered a factor that would lead to acute readmission, this cause may be included in the context of the study. Limitations This study has some limitations. Firstly, it includes data from a single hospital, with a relatively small sample. In addition, it is not possible to evaluate the secondary outcomes satisfactorily, since the sample size is not so big. Moreover, it was impossible to have a control group in parallel to the study, since it was conducted in two distinct periods, and the motivation of the team may imply different results. However, note that the motivation of the team is one of the benefits of the accreditation process. Another limitation was that the data of this study were secondary and were derived from medical records, although the researchers made sure they conducted an active search for any information that might be missing or doubtful. Conclusions In conclusion, after the ONA 3 accreditation process, there was a reduction in hospital stay. There were no significant differences in the frequency of hospital mortality or combined clinical outcomes, as well as in the length of hospital stay at the CCU.