The golden hour: the feasibility of a quality improvement project to decrease the time to antibiotic administration in children with cancer and febrile neutropenia in Jordan.
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BACKGROUND: Febrile neutropenia (FN) is a potentially life-threatening condition in pediatric oncology; early antibiotic initiation is associated with improved survival. A quality improvement (QI) project was implemented in the Pediatric Emergency Room (ER) to improve the timeliness of antibiotic administration. METHODS: Starting in July 2019, the project was designed using the Find, Organize, Clarify, Understand, and Select-Plan, Do, Check, and Act (FOCUS-PDCA) framework. We aimed to give antibiotics within 60 min of ER arrival for children with suspected FN. High-risk patients received antibiotics without waiting for blood count confirmation. A structured staff education campaign was conducted over 6 months, and performance metrics were continuously monitored. Outcomes were compared with retrospective data from December 2018 to June 2019. RESULTS: The pre-intervention cohort included 119 children with cancer, accounting for 158 FN episodes. From July 2019 to December 2024, during the intervention period, 697 children with cancer (median age 4.7 years; IQR 2.6-9.2 years; 54% male) presented with FN, accounting for 1,164 ER visits (median 1 visit/patient; range, 1-11). The median absolute neutrophil count (ANC) at presentation was 50 cells/μL (IQR, 0-180 cells/μL). Median time from ER arrival to antibiotic administration decreased from 120 min (IQR, 97-143) at pre-intervention baseline to 50 min (IQR, 40-65) across the implementation period (p < 0.01). The time from antibiotic ordering to first dose remained stable (median 32 min; IQR, 25-40), while time from arrival to antibiotic ordering decreased from 53 to 15 min (p < 0.01). Compliance with the 60 min target improved from 22% in the pre-intervention period to a sustained 85%-90% range across 2021-2024, with the ≥90% target met in all 12 months of 2021 and compliance declining to 85.8% in 2024. The target was increased to 90% in September 2020. CONCLUSION: A structured Golden Hour QI initiative is feasible, effective, and associated with substantial and sustained improvement in antibiotic timeliness in the Middle East region, without additional funding, staffing, or technology. The core drivers of sustained improvement were automatic Category-A triage for children with cancer presenting with fever, pre-ANC antibiotic initiation for high-risk cases, and monthly audit-feedback cycles - all implementable within existing workflows.