title: Integrated audit as a means to implement unit protocols: a randomized and controlled study.
abstract: BACKGROUND
  Great emphasis is placed on the need to base assistance activities on efficacy evidence. Nevertheless, it is demonstrated that the mere knowledge of scientific recommendations is not sufficient to determine changes in practice. Many elements can influence the operators' behaviour, so that comprehensive strategies are needed to change wrong or not evidence-based practices.
  
  
  OBJECTIVE
  The aim was to compare the efficacy of two protocol implementation strategies: clinical-organizational integrated audits with feedback and presence of facilitators in the departments versus standard observation.
  
  
  METHODS
  Cluster-randomized, controlled and open trial methods were used. Implementation was investigated for protocols regarding the prevention of pressure lesions and the management of peripheral and central venous catheters. For both protocols, a checklist with the indicators needed for the evaluation was created. The study was divided into five time points. For the initial and final investigation, evaluators filled-in the checklists for both study groups; for the three intermediate investigations, the checklists were self-filled by the operators of the control group, while the operators of the experimental group received the intervention.
  
  
  RESULTS
  For almost all indicators, the data show an increment in the adoption of correct practices. Nevertheless, the last investigation shows a significant (P < 0.05) difference between the two groups in favour of the experimental group: 12 process indicators versus one for catheter management protocol and seven versus one for protocol on pressure lesions.
  
  
  CONCLUSIONS
  The main strong point of the study lies in carrying out an intervention aimed at improving the operators' adoption of two protocols as a whole, rather than of single procedures. The audit intervention allowed to highlight some more subjective criticalities important in determining the success or failure of the implementation of effective practices.
authors.affiliation: Department of Public Health and Microbiology, University of Torino, Torino, Italy.
authors.forename: Lorena
authors.initials: L
authors.lastname: Charrier
authors.forename: Maria Cristina
authors.initials: MC
authors.lastname: Allochis
authors.forename: Maria Rita
authors.initials: MR
authors.lastname: Cavallo
authors.forename: Dario
authors.initials: D
authors.lastname: Gregori
authors.forename: Franco
authors.initials: F
authors.lastname: Cavallo
authors.forename: Carla Maria
authors.initials: CM
authors.lastname: Zotti
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D002405:Catheterization, Central Venous / Q000451:nursing; D002406:Catheterization, Peripheral / Q000451:nursing; D016000:Cluster Analysis; D004059:Diffusion of Innovation; D055318:Evidence-Based Nursing / Q000193:education / Q000458:organization & administration; D030141:Feedback, Psychological; D019983:Guideline Adherence / Q000458:organization & administration; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007558:Italy; D008875:Middle Aged; D009731:Nursing Audit / Q000458:organization & administration*; D015403:Nursing Evaluation Research; D009741:Nursing Staff, Hospital / Q000193:education / Q000458:organization & administration / Q000523:psychology; D017410:Practice Guidelines as Topic; D003668:Pressure Ulcer / Q000517:prevention & control; D019984:Quality Indicators, Health Care; D012044:Regression Analysis