title: [Protocols implementing in a university hospital. An assessment of various methods].
abstract: OBJECTIVE
  To establish a method for evaluating, in a systematic and periodic way, the degree of compliance with the protocols currently being used in the hospital.
  
  
  METHODS
  Experts from the hospital designed 6 protocols which were later approved by consensus by several committees and agreed by Medical Direction. The doctors were informed of the new protocols by means of info-sessions and printed materials. In order to evaluate to what extent the protocols were complied with, we carried out a number of longitudinal and cross-sectional studies depending on how often the protocols are used.
  
  
  RESULTS
  The study involved 2,190 patients. Cross-sectional studies. Surgical antimicrobial prophylaxis protocol: compliance with the application forms was 83.3% and for surgical interventions it was 64.3%. It should be noted that adherence improved with time. Sliding-scale insulin therapy: compliance improved during the observation period from 54 to 71.1%. Prevention of NSAID induced gastropathy: after 6 months a significant improvement was observed in relation to the previous phase. Pain treatment: of the 117 analgesics prescribed on-demand in the previous phase, 27.3% were administered, as well as 68.4% of a total of 95 fixed prescriptions. In the phases previous to setting up these protocols, adherence ranged from 0 to 68.4%. One year later, adhesion has improved significantly for all the evaluated protocols. Longitudinal studies. Community acquired pneumonia: adhesion was 60.8%, while non significant differences were observed according to severity. Transitory ischemic accident: compliance evaluation showed an adherence value of 81.8%.
  
  
  CONCLUSIONS
  When the degree of compliance is high, follow-up studies may be spaced out in time. If not, the reasons for this low compliance must be identified and measures must be taken. Follow-up studies must be carried out more often when protocols have just been set up and less frequently as adherence improves.
authors.affiliation: Servicio de Farmacia, Hospital Universitari Sagrat Cor, Barcelona. hscfarmacia@inicia.es
authors.forename: M
authors.initials: M
authors.lastname: Aguas Compaired
authors.forename: M
authors.initials: M
authors.lastname: Pons Busom
authors.forename: J
authors.initials: J
authors.lastname: Delàs Amat
authors.forename: B
authors.initials: B
authors.lastname: Eguileor Partearroyo
mesh_terms: D003430:Cross-Sectional Studies; D017723:Drug Utilization Review; D019983:Guideline Adherence / Q000592:standards* / Q000706:statistics & numerical data; D006785:Hospitals, University / Q000592:standards* / Q000706:statistics & numerical data; D006801:Humans; D008137:Longitudinal Studies; D010607:Pharmacy Service, Hospital / Q000592:standards* / Q000706:statistics & numerical data; D015397:Program Evaluation; D011785:Quality Assurance, Health Care / Q000379:methods