A multi-year partnership between IHI and St. Jude Global to spread best practices for managing pediatric cancer patients presenting to the emergency department with fever

Summary

Infections are the first cause of mortality amongst children with cancer. The “Golden Hour” – administration of antibiotics within an hour – has demonstrated to be effective in reducing infections and infection-related complications and mortality in pediatric hematology-oncology patients with fever (PHOPf) who present to the Emergency Department (ED). Since 2019, IHI and St. Jude Global have been partnering to effectively spread the Golden Hour across Latin America using two Quality Improvement Collaboratives (QICs) and two Improvement Science In Action (ISIA) programs, with the aim of increasing the percentage of PHOPf who receive the first dose of antibiotics within the Golden Hour to 70%.

The QICs used a modified Breakthrough Series Collaborative Model coupled with QI training. The first QIC ran between May 2019 and November 2020 and included 23 hospitals from Mexico. The second QIC ran between November 2021 and May 2023 and included 85 participating hospitals from Mexico, Central America, and South America.

The MAS Collaboratives exceeded their aims (see specific results below) and simultaneously created an enduring, multinational network of clinicians trained in QI – an invaluable resource for future improvements.

• 60% increase in patients receiving the first dose of antibiotics within 60 minutes
• 60% decrease in incidence of sepsis
• An estimated 347 cases of sepsis prevented
• An estimated 27 deaths avoided
• An estimated 5,458 inpatient bed days reduced
• At least (an estimated) $8-10 million in avoided costs

Background

One-third of pediatric patients undergoing chemotherapy develop febrile neutropenia. In low- and middle-income countries (LMICs), treatment-related mortality associated with infectious complications ranges between 10 and 25%; while in high-income countries (HICs) it is under 2%. Since infections pose significant risks to children receiving cancer treatment, the evidence-based best practice is to administer antibiotics within 60 minutes from triage. This time period is known as the “Golden Hour” given its effectiveness in reducing infection-related complications and mortality.

Between 2016 and 2019, as part of an effort to spread this best practice, St. Jude Global and its Mexico Regional Program initiated pilot quality improvement (QI) programs aimed at ensuring this practice in Tijuana, Culiacan, and Guadalajara. In 2019, the Mexico Regional Program launched the first Mexico in Alliance with St. Jude (MAS) Golden Hour Collaborative in partnership with the Institute for Healthcare Improvement. The first MAS Collaborative engaged 23 hospitals in Mexico and increased the percentage of pediatric hematology-oncology patients with fever receiving the first dose of antibiotics from a baseline mean of 40% to 78% across the participating sites over a period of 18 months.

The success of this first MAS Collaborative led to an expanded initiative – the 2nd MAS Collaborative.

Approach

Collaboratives are QI programs that use IHI’s Breakthrough Series Model – an approach developed by IHI in the 1990s with a simple but proven structure that facilitates improvement across a large cohort of participating teams. The goal of all Breakthrough Series (BTS) collaboratives is to bridge the gap between what we know works, and what we actually do in health care. 

The 2nd MAS Collaborative, like the first, followed the BTS model, and served as a mechanism to scale the Golden Hour to 72 hospitals in Mexico and 13 hospitals across five additional Latin American countries.

The BTS model comprises five essential elements: 1) focus on one specific and shared topic; 2) continuous support from QI and subject-matter experts; 3) participation of teams from multiple sites or organizations; 4) the use of a common theory of change and measurement strategy; and 5) the utilization of the Model for Improvement (MFI) as its guiding framework. The BTS model was coupled with two QI training programs to build local QI capacity and capability in an effort to strengthen quality within the participating institutions and to ensure sustainability.

The MAS Collaboratives were organized around in-person and virtual learning sessions and action periods. During the action periods, teams tested change ideas using Plan-Do-Study-Act (PDSA) cycles based on a common theory of change; attended monthly learning calls; received coaching; and reported PDSAs and data into a shared repository. 

The BTS model helped enable a significant scaling up from the initial 23 sites in Mexico to 72 hospitals in Mexico and 13 hospitals spread across Brazil, Haiti, Panama, Paraguay, and Peru. 

The program team worked with participants to test and refine a theory of change articulated in a driver diagram – a tool commonly used by IHI to link the overall aim of the program to specific change ideas to test. In the 2nd “Golden Hour” Collaborative, the teams organized and tested change ideas according to the primary drivers of: 1) access and availability of supplies and medications; 2) an effective data management and learning system; 3) promoting early identification of fever at home and timely access to care; 4) increasing clinical process reliability; and 5) promoting teamwork and effective communication. 

The learning system captured both quantitative data and qualitative data produced through interviews and focus groups. They used this data to evaluate the impact of changes, re-design changes, and surface new changes with potential. 

Results

In addition to the results listed below, participating in the MAS Collaboratives helped build local capability in the methods and tools of improvement. The participating teams now have the ability to initiate new QI projects and programs and collect and analyze the data needed to assess impact and inform future initiatives.

The MAS Collaboratives also produced an enduring regional network of clinicians from different countries who have already worked together on spreading and implementing a proven best practice. These additional benefits are not accidental – they are the intended result of IHI’s approach to collaborative improvement.

The 2nd MAS Collaborative achieved its goals and produced the following results:

• 60% increase in patients receiving the first dose of antibiotics within 60 minutes (see chart below)
• AutoShape 2, Textbox60% decrease in incidence of sepsis
• An estimated 347 cases of sepsis prevented
• An estimated 27 deaths avoided
• An estimated 5,458 inpatient bed days reduced
• At least (an estimated) $8-10 million in avoided costs

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Related Information

• The Power of Applying Improvement Science to the COVID-19 Response
• In the 'Golden Hour,' antibiotics save lives in Latin America