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.

To train 100% of the nurses (n 5 28) in the PHOU and achieve a significant increase in knowledge (.90% gain posttest) as the first step in implementing the Golden Hour. c To train all parents of newly diagnosed patients on the basic concepts of treating fever at home. c To continue development of the Golden Hour, decrease time to antibiotic (TTA) administration to ,1 hour in all patients with NF at the GHT PHOU, and measure the impact of the initiative on sepsis rates, admission rates to the Pediatric Intensive Care Unit (PICU), and hospital length of stay.cTo ensure that 100% of supplies needed each day are in the Golden Box and prevent shortages of supplies. MethodsWe conducted a 4.6-year prospective cross-sectional study in 4 phases that included patients with NF who were admitted to the PHOU.

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