Problem: A retrospective audit of management of oesophageal varices in patients with cirrhosis identified the need to improve adherence to guidelines. Design: Prospective audit of the effect of disseminating guidelines in 2004; prospective audit of the effect of a nurse coordinator for oesophageal variceal screening and surveillance from 2005 to 2008. Setting: A major public hospital in Australia 2001e2008. Patients with cirrhosis of the liver and those who had experienced a variceal bleed were studied. Key measures for improvement (1) Adherence with primary prevention protocols for prevention of primary variceal bleeding in patients with cirrhosis of the liver. (2) Adherence with protocols for acute management of variceal bleeding and secondary prevention of bleeding. Strategies for change Local protocols were developed and disseminated. A nurse coordinator was introduced to manage the primary prevention process according to a clinical protocol. Effects of change The introduction of a nurse coordinator to manage the primary prevention process resulted in dramatic and rapid improvements in primary prevention. This has been maintained with our target of 90% adherence being achieved for the last 3 years. Lessons learnt Disseminating guidelines had little effect on primary prevention practice. Less than 1 year after a nurse coordinator was introduced to manage primary prevention, adherence to primary prevention guidelines increased from 13% to 79%. However, significant improvements in the management of acute variceal bleeding where medical staff have a clear responsibility for patient care were achieved through the development and dissemination of clear clinical protocols and the introduction of auditing and feedback mechanisms.