The Golden Hour: Sustainability and Clinical Outcomes of Adequate Time to Antibiotic Administration in Children with Cancer and Febrile Neutropenia in Northwestern Mexico.
The Golden Hour: Sustainability and Clinical Outcomes of Adequate Time to Antibiotic Administration in Children with Cancer and Febrile Neutropenia in Northwestern Mexico.
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DOI：
10.1200/go.20.00578
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发表时间：
2021-05
影响因子：
4.5
通讯作者：
Caniza MA
中科院分区：
文献类型：
--
作者：
Gonzalez ML;Aristizabal P;Loera-Reyna A;Torres D;Ornelas-Sánchez M;Nuño-Vázquez L;Aguilera M;Sánchez A;Romano M;Rivera-Gómez R;Relyea G;Friedrich P;Caniza MA
抗生素给药时间（TTA）是高收入国家儿科癌症环境中常用的护理标准。改善发热性中性粒细胞减少症（FN）癌症患者结局的有效干预措施通常涉及及时和适当的抗生素给药。我们在墨西哥一个资源有限的儿科癌症中心评估了当地适应的多模式策略在减少TTA方面的有效性。我们在2014年1月至2019年4月期间进行了一项前瞻性观察性研究。三相（第一阶段：第二阶段：巩固，第三阶段：实施了多模式改善战略，将系统变革、FN指南制定、教育、审计和监测、指导以及传播结合起来，以减少住院和门诊地区的TTA。在第一阶段和第三阶段，使用经过验证的工具对可持续性因素进行了衡量。我们的人群包括105名癌症儿童，其中204例FN事件。基线评估显示，只有50%的患者在处方后60分钟内接受抗生素治疗（中位时间：住院患者，75分钟;门诊患者，65分钟）。在实施我们的改善策略后，在处方后60分钟内接受抗生素治疗的病人比例增加到88%。在研究的三个阶段中，我们显著降低了两个临床领域的TTA中位数。在III期（可持续性）中，住院区的中位TTA为40分钟（P = .023），门诊区为30分钟（P = .012）。脓毒症患者比例从30%（基线）降至5%（III期）（P = 0.001）。我们的研究结果表明，在资源有限的情况下，当地适应的多模式干预可以减少TTA。指导和传播是改善FN相关临床结局的多模式策略的新组成部分。改善当地基础设施、持续监测系统和领导参与是五年期间实现可持续性的关键因素。
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. 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. 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). 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.