The Golden Hour: Sustainability and Clinical Outcomes of Adequate Time to Antibiotic Administration in Children with Cancer and Febrile Neutropenia in Northwestern Mexico

Abstract

PURPOSE Time to antibiotic administration (TTA) is a commonly used standard of care in pediatric cancer settings in high-income countries. Effective interventions to improve outcomes in cancer patients with febrile neutropenia (FN) often address timely and appropriate antibiotic administration. We assessed the effectiveness of a locally adapted multimodal strategy in decreasing TTA in a resource-constrained pediatric cancer center in Mexico. METHODS We conducted a prospective observational study between January 2014 and April 2019. A three-phase (phase I: execution, phase II: consolidation, phase III: sustainability) multimodal improvement strategy that combined system change, FN guideline development, education, auditing and monitoring, mentoring, and dissemination was implemented to decrease TTA in inpatient and ambulatory areas. Sustainability factors were measured by using a validated tool during phases I and III. RESULTS Our population included 105 children with cancer with 204 FN events. The baseline assessment revealed that only 50% of patients received antibiotics within 60 minutes of prescription (median time: inpatient, 75 minutes; ambulatory, 65 minutes). After implementing our improvement strategy, the percentage of patients receiving antibiotics within 60 minutes of prescription increased to 88%. We significantly decreased median TTA in both clinical areas during the three phases of the study. In phase III (sustainability), the median TTA was 40 minutes ( P = .023) in the inpatient area and 30 minutes ( P = .012) in the ambulatory area. The proportion of patients with sepsis decreased from 30% (baseline) to 5% (phase III) ( P = .001). CONCLUSION Our results demonstrate that locally adapted multimodal interventions can reduce TTA in resource-constrained settings. Mentoring and dissemination were novel components of the multimodal strategy to improve FN-associated clinical outcomes. Improving local infrastructure, ongoing monitoring systems, and leadership engagement have been key factors to achieving sustainability during the 5-year period.

Assessment of Barriers and Enablers to Implementation of a Pediatric Early Warning System in Resource-Limited Settings

“…The mentorship and shared experience of other geographically and organizationally similar resource-limited centers served as an enabler to implementation. These findings support recent global efforts to improve outcomes for children with cancer through local empowerment, regional collaborations, and international partnerships, and are a model for the global scale of strategies to support implementation of evidence-based interventions such as PEWS.…”

Triple-hit explanation for the worse prognosis of pediatric acute lymphoblastic leukemia among Mexican and Hispanic children

“…Limited access to adequate pediatric intensive care, geographical and social barriers for well-timed detection and attention of complications for patients in treatment favor the risk of death during treatment for patients, not only in LMIC like Mexico but also for patients in HIC living in Hispanic enclaves ( 13 , 42 , 43 ).…”

Diagnosis and Management of Febrile Neutropenia in Pediatric Oncology Patients—A Systematic Review

“…Regarding the golden hour, which refers to the time interval between patient triage to antibiotic treatment initiation, several guides strongly recommend its use [ 11 , 31 , 32 ]. The time to antibiotics administration is considered a strong indicator of the quality of care provided in the cancer facility, and any initiative to decrease the mortality and morbidity in patients with FN should promptly address this.…”

“…Patients not meeting any of the aforementioned criteria are included in the low-risk group, while those meeting criteria and having sustained fever and neutropenia for over 96 h are defined as having persistent high-risk febrile neutropenia [ 6 , 10 ]. Either way, prompt empiric broad-spectrum antibiotic administration is collectively recommended by the FN guidelines and professional medical societies [ 11 , 12 , 13 ]. The increased duration until antibiotic administration is initiated has been associated, in the pediatric setting, with higher rates of sepsis and higher rates of intensive care admission and death, thus prompting the term “golden hour” as the recommended timeframe between FN patient presentation to the start of the antibiotic administration [ 7 , 14 ].…”