Colección de posters

FEASIBILITY OF CENTRALIZED ACUTE LYMPHOBLASTIC LEUKEMIA TESTING IN MEXICO IN ALLIANCE WITH ST. JUDE (MAS) INSTITUTIONS THROUGH A QUALITY IMPROVEMENT METHODOLOGY APPROACH Nataly Mercado1, Naomi Echeandia-Abud2, Pablo González-Montalvo3, Hugo Antonio Romo-Rubio4, Dinora Aguilar-Escobar5, Daniela Arce-Cabrera6, Karla Guerrero-Gómez1, Julio Alejandro Moreno-Serrano5, Margarita González-Zamorano7, Sergio Garay-Sánchez5, Patricia Judith Mendoza-Sánchez8, Eliazar Parra-Cárdenas1, Ana Elena Soto-Fernández1, Paola Friedrich2 1Casa de la Amistad para Niños con Cáncer, México en Alianza con St. Jude, Ciudad De México, México, 2St. Jude Children's Research Hospital, Global Pediatric Medicine, Memphis, TN, United States of America,

3Hospital General "Dr. Agustín O'Horan", Servicios de Salud de Yucatán, Oncology, Mérida, México, 4Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Oncology, Guadalajara, México, 5Hospital Infantil Teletón de Oncología,

Laboratory, Querétaro, México, 6Hospital Pediátrico de Sinaloa, Oncology, Culiacan, México, 7Hospital General con Especialidades "Juan María de Salvatierra", Oncology, La Paz, México, 8Hospital Infantil Teletón de Oncología, Education and Research Department, Querétaro, México

BACKGROUND BACKGROUND BACKGROUND

METHODS METHODS RESULTS

The Bridge Project is a multi-site collaboration and quality improvement initiative to centralize diagnostic studies for children with suspected acute lymphoblastic leukemia (ALL) within the Mexico in Alliance with St. Jude (MAS) collaborative group. It has exposed the variability of techniques used to obtain samples, packaging, and shipment processes. We present the results of the first cohort of participant institutions that have implemented the Quality Improvement (QI) methodology to achieve standardization.

We collected data from 348 patients with suspected ALL from four institutions from June 2019 to June 2023. All patients benefited from a complete diagnostic report; 291 (83%) cases were confirmed with ALL diagnosis and 937 samples were shipped. We observed improvement in most outcome, process, and balance measures. We documented a reduction in prevalent critical errors, labeling, temperature and volume. Participants reported high satisfaction with the project (>90%). Successful change ideas were registered in a shared database to guide implementation in new participating centers.

Outcome measure

OBJECTIVES

18% 16% 12%

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14%

CL

12% 10%

11.7%

LCL

8%

6.5%

6% 4% 2%

1.3% 48

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0% 8

•Full MRD​

UCL

16%

7

•Full MRD​

Month of participation

Process measure

The consensus-derived diagnostic panel includes morphology, immunophenotype, DNA index, FISH, karyotype, and MRD.

Average shipment time from participating hospitals to central laboratory X-Chart

Target: < 48 hours

50

Time (in hours)

45

METHODS

40

UCL

35

37.8

CL

30

30.5

LCL

25

23.3

20 15 10 5

Theory of change • Aim: To reduce to zero the number of critical errors in samples sent through the Bridge Project to the centralized laboratory.

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Month of participation

Process measure

Percentage of labeling errors in ALL samples shipped to the centralized laboratory P-Chart

35% 30% 25%

UCL

20% 15%

11.9%

CL

10% 5%

2.1% 48

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0% 1

We utilized the Model for Improvement1: defined aim, theory of change, a family of measures, and iteration for improvement through Plan-Do-Study-Act (PDSA) cycles. Patient samples (children aged 0-18 years old) were shipped from the treatment facility to the central laboratory. Upon arrival, the laboratory evaluated the samples against 14-item criteria (9 critical and 5 non-critical based on their impact on sample viability/reliability) and collected de-identified information in a database. Participating institutions ran and documented PDSA cycles to decrease the number of errors.

0

Percentage

Day 84

Percentage of total errors (critical and non-critical) in ALL samples shipped to the centralized laboratory P-Chart

6

• •Morphology (BMA +/- biopsy)​ •Full MRD​

18%

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•Morphology (BMA +/- biopsy)​ •Full MRD only in case of morrow M2 or M3​

Process measure

20%

4

Day 29

1

Month of participation

3

•N/A​

0.0%

Target: 0% critical errors

0%

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2%

2

•MRD Lite​

4.0%

4%

1

Day 15

LCL

6%

Percentage

•Morphology (BMA +/- biopsy)​ •Immunophenotype​ •DNA index​ •Karyotype​ •FISH: BCR-ABL, MLL-AF4, •CDKN2A, TLX1, TLX3, TRA/D​

9.0%

8%

Strain T

•Morphology (BMA +/- biopsy)​ •Immunophenotype​ •DNA index​ •Karyotype​ •FISH: BCR-ABL, ETV6RUNX1, MLL-AF4, EA2PBX1, iAMP21​

CL

10%

Consensus derived Diagnostic panel for the Bridge Project Strain B

UCL

14% Percentage

In addition to securing access to a comprehensive diagnostic panel, the Bridge Project aims to standardize ALL sample procurement, processing and shipment within participating hospitals. All samples are shipped and processed in a centralized Laboratory (Hospital Infantil Teletón de Oncología) in Mexico.

Diagnosis

Percentage of critical errors in ALL samples shipped to the centralized laboratory P-Chart

20%

Month of Participation

Process measure

70%

Percentage of volume errors in ALL samples shipped to the centralized laboratory P-Chart

60%

Percentage

50%

UCL

40% 30%

CL

20%

Acknowledgments Bibliography

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0% Month of participation

Most common errors (Median)

Pareto Chart

• Measurement strategy examples: 1. Outcome: % events with zero critical errors​ 2. Process: % events that arrive w/in <48hrs 3. Balance: % satisfaction among clinicians

11.8%

10%

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• Driver Diagram: 1. Access to equipment and supplies​ 2. Process standardization and reliability 3. Meeting for norms and regulations​ 4. Efficient data management 5. Communication and teamwork

18% 16% 14% 12% 10% 8% 6% 4% 2% 0%

CONCLUSIONS

15.0%

4.0%

3.0%

3.0%

3.0% 0.0%

0.0%

Hematology/Oncology leaders and clinical research coordinators and laboratory staff of participant hospitals.

Administrative staff from Casa de la Amistad para Niños con Cáncer.

Special gratitude to Erika Casillas Toral, Elianneth Rey, Verónica Espinosa and the Mexico in Alliance with St. Jude team.

1Institute for Healthcare Improvement. (2023). Model of Improvement. Retrieved from

https://www.ihi.org/resources/Pages/HowtoImprove/default.aspx

Our results show that centralization of specialized diagnostic services is feasible, can effectively build local capacity, standardize the process of sample procurement, packaging, and shipment, and increase access to a standardized diagnostic panel for children with suspected ALL. A replica of the model across other specialized laboratories in Mexico is underway.

Contact information

mas-puenteALL@stjude.org

Contextual factors associated with the success of the Golden Hour Multi-country Quality Improvement Collaborative Facundo Jorro-Barón1, Kelly Estrada-Orozco1, Jafet Arrieta1,2, Fernando Chavarría1, Lilian Delgado-Espejel3, Luis Delgado1, Francis Duran1, Cecilia Enriquez-Chavez1, Naomi Echeandia-Abud4, Miriam Gonzalez-Guzman4, Viviana Rodriguez1, Paola Friedrich4 1 Institute for Healthcare Improvement, Boston, MA, USA 2 Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA 3 México en Alianza con St. Jude, CDMX, Mexico 4 Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN USA

BACKGROUND BACKGROUND

METHODS METHODS METHODS

• A series of contextual factors contribute to the success of Quality Improvement Collaboratives (QIC) in real-world settings.

• This 18-month QIC followed the Breakthrough Series Model coupled with two QI capability-building programs.

• Between November 2021 and February 2023, 85 institutions from six Latin American countries (Brazil, Haiti, Mexico, Panama, Paraguay, and Peru) participated in the 2nd Mexico in Alliance with St. Jude Golden Hour Collaborative (2nd MAS Collaborative).

• We built a multivariate logistic regression model to assess the factors that contribute to success:

• The aim was to reduce the time to antibiotic administration to ≤60 min among febrile pediatric hematology-oncology patients (fPHOP) presenting to the emergency department, from a baseline of 46% to ≥70% by May 2023.

• The overall goal was achieved, with varying results across institutions.

OBJECTIVES • This study aimed to identify the contextual factors associated with the success of the 2nd MAS Collaborative.

Figure 1. Model for Understanding Success in Quality (MUSIQ)

a) Six dimensions of the Model for Understanding Success in Quality (MUSIQ: external environment, organization, QI support and capacity, microsystem, and QI team); figure 1. b) Active participation in activities of the collaborative (³60% learning sessions and coaching attendance). c) Key drivers from the change theory worked on (1. clinical and paraclinical reliability; 2. learning systems; 3. effective teamwork and communication; 4. early fever identification; 5. effective access to medicines and supplies); figure 2. d) Intervention exposure time. e) Participation in the 1st MAS Collaborative.

• We defined success as having achieved their local aim or a proportion 70% of fPHOP receiving antibiotics in ≤60min.

Figure 2. Driver Diagram (Change Theory)

RESULTS

CONCLUSIONS

RESULTS • The following factors were associated with success: • active participation in activities of the collaborative (OR 3.8); • having worked on driver 1 (OR 11.3) and driver 5 (OR 11.9) of the change theory driver diagram; and • having participated in the 1st MAS Collaborative (OR 3.3).

CONCLUSIONS • Understanding the contextual factors associated with success of QICs in real-world settings is key to inform their design and implementation, and to determine the support that should be provided to institutions to help them achieve and sustain results.

• Other factors were not conducive to success.

REFERENCES • Kaplan H, Provost L, Foroehle C, et al. The Model for Understanding Success in Quality (MUSIQ): building a theory of context in healthcare quality improvement. BMJ Quality & Safety (2011). doi;10.1136/bmjqs-2011-000010 • The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003.

Multisite implementation of CAREREG, a hospital-based cancer registry as a cohort in Mexico Guerrero-Gomez K1, Ferrara G2, Muniz-Talavera H2, Alvarez-Corrales M1, Casillas-Toral E1, Hernandez-Garcia M2, Lopez- Facundo A3, Gonzalez-Ramella O4, Echeandia-Abud N2, Graetz D2, Bhakta N2, Friedrich P2 1. Casa de la Amistad para niños con cancer I.A.P., Ciudad de Mexico, Mexico. 2. St. Jude Children’s Research Hospital, Memphis, USA. 3. Hospital Materno Infantil del Instituto de Seguridad Social del Estado de México y Municipios, Toluca, Mexico. 4. Hospital Civil de Guadalajara ”Dr. Juan I. Menchaca”, Guadalajara, Mexico.

BACKGROUND

In Mexico, according to the local Health Ministry, childhood cancer is the leading cause of disease-related mortality in children RESULTS between 5-14 years. An estimated 6,984 new pediatric cancer cases occur yearly. No national population-based cancer registry exists despite its importance for surveillance and health policies.

RESULTS

15 52

OBJECTIVES In 2022, Mexico in Alliance with St. Jude (MAS) collaborating hospitals were invited to begin as a cohort, implementing the SJCARES (CAREREG) Registry, a hospital-based cancer registry designed for institutions in low- and middle-income countries and developed by St. Jude Children’s Research Hospital (SJCRH), with support from a diverse expert panel.

Figure 2: First MAS-SJCARES Registry Cohort participating sites

Due to the participating sites’ needs, the planned timeline needed to be extended by four months in the training phase. This was the first cohort approach for the registry implementation, and administrative delays for test cases and platform access also impacted the duration of implementation (Table 2). The 15 sites have completed the test cases satisfactorily, and 14 are entering METHODS data.

Twenty-three hospitals from MAS with a data transfer agreement Activity Average duration Range with SJCRH previously signed were invited to join the first MAS Online training 5.2 months (3.7 - 7.2) SJCARES Registry cohort. The implementation process included: Test cases 1 month (0.4 - 2.1) •Every site created a local team and completed online training in Data entry start 1.3 months* (0.4 – 1.9)* Online training start to data entry start 8.8 months* (8.1 – 11.2)* an educational platform (Table 1).

Administrative time 1.6 months (0.83 – 2.8) •Biweekly meetings with the cohort were held to reinforce *14/15 sites concepts and answer questions.

Table 2: First MAS-SJCARES Registry Cohort implementation phases duration •Each site entered test cases, and a feedback meeting was Based on each institution's yearly new childhood cancer diagnosis, conducted. >800 patients are expected to be registered yearly, corresponding •Access to the registry platform was granted after completing to 12% of the country’s expected incidence (~7,000).

The sites have the previous steps (Figure 1).

Following the Knowledge to Action framework (K2A) for been granted access to the registry platform asynchronously due to their progress through the phases.

The 14 sites entering data have implementation, semi-structured interviews will be conducted within six months of data entry and repeated six months later to registered 436 new cases as of August 2023; this represents 51% of the expected yearly new cases diagnosed in the 15 participating assess barriers and facilitators. Outcomes and sustainability will be sites (Figure 3). evaluated 12 and 24 months after beginning data entry.

Course

Local Registry Director

MD Monitor

Data Entry Specialist (Medical Background)

Data Entry Specialist (No Medical Background)

Introduction to pediatric oncology

Optional

Optional

Optional

Required

Data abstraction

Optional

Optional

Required

Required

Cancer registry

Required

Required

Required

Required

TrialMaster® training

Optional

Required

Required

Required

1° MAS-SJCARES Cohort status

1° MAS-SJCARES Cohort data entry

1

436 14

15

Table 1: Training core Launching session February 22, 2023

Training start June 7, 2022

Trainning

Test cases

November, 2022-March, 2023

Test cases

Data entry

Entering data

Pending entering data

Figure 3: First MAS-SJCARES Registry Cohort status

CONCLUSIONS Enrollment

February 22- April 8, 2022

Online training June-November, 2022

Data entry March,2023

Figure 1: First MAS-SJCARES Registry Cohort Implementation Timeline

RESULTS

The cohort-based approach has accelerated the process for implementation, optimizing human resources, knowledge sharing, and timely training. With this first cohort, we have generated implementation insights and inferences to help the implementing sites. We have and will continue to gather knowledge to inform future implementation of this and other comparable interventions.

We have finished the enrollment and begun the training for a second cohort launched in August 2023, improving the process with the lessons learned from the first cohort so far.

Fifteen (65%) hospitals were able to join the first cohort. Fifty-two team members received online training with prerecorded lectures in Cure4Kids. Follow-up and learning sessions happened twice a month during the training phase and moved to once a month when all the sites achieved access to the data entry platform. By September 2023, we had 21 meetings with an 80% average CONTACT attendance of the participating sites. mexico@stjude.org

BUILDING LOCAL QUALITY IMPROVEMENT CAPACITY TO ACCELERATE OWNERSHIP OF QUALITY IMPROVEMENT PROJECTS: THE MEXICO IN ALLIANCE WITH ST. JUDE (MAS) EXPERIENCE Authors: Lilian Delgado Espejel 1, Francis Durán-Mellado2, Jafet Arrieta2, Naomi Echeandia-Abud3, Paola Friedrich3 1Casa de la Amistad para Niños con Cáncer, México en Alianza con St. Jude, Ciudad De México, México 2Institute for Healthcare Improvement, Department of Global Health, Boston MA, United States 3St. Jude Children's Research Hospital, Global Pediatric Medicine, Memphis, TN, United States

BACKGROUND BACKGROUND BACKGROUND

• Infrastructure and resource allocation investments haven’t been enough to tackle unequal access, experience and outcomes in healthcare.

• Enhancing Quality Improvement (QI) education and training local healthcare professionals improves the system’s capability.

• St. Jude Global offered the IHI Improvement Coach Program in 2021 to 100 healthcare professionals in 5 Latin American countries.

METHODS RESULTS METHODS

QI coaches referred a variety of approaches to: • Uncover the fundamental needs and challenges of teams, • Establishing ownership from the outset by involving a diverse group of stakeholders, • Identifying the appropriate solution by being open to rapid experimentation and potential failure.

The following table summarizes successful tools and what needs to be reinforced.

• Ten (from 53 graduates) were selected to work as QI coaches for the 2nd MAS Golden Hour Collaborative; a project aiming to increase the percentage of febrile hemato-oncological patients who receive the first dose of antibiotics within 60 min of arrival from a baseline of 46% to ≥70% between November of 2021 and May of 2023 in 85 participating healthcare institutions.

Table 1: Effective Tools and Prevalent Barriers in Coaching Sessions

• Each coach mentored 3-5 quality improvement teams; which consisted of 4-6 members each.

•

• The aim of this project was to explore the experiences, approaches, and strategies of local QI coaches in implementing and owning QI projects to underpin capacity-building mechanisms.

Most effective tools • Root cause analysis

• •

MAIN FINDINGS

•

Incorporating local (QI) coaches serves to enhance capacity and optimize care for children with cancer and; ultimately, helps to build a more predictable care delivery system.

•

Local QI coaches lead to sustained improvement in healthcare outcomes and accelerate QI project ownership in large-scale projects.

•

It is important to make training relevant to the context, emphasizing the prevalent barriers to more effective decision-making.

•

By training local QI coaches, systems can become more self-sufficient and less reliant on external support.

METHODS

• We conducted semi-structured virtual interviews with the 11 coaches to investigate the methods employed during their coaching sessions, strategies that resulted in successful implementations, and the most frequently encountered obstacles.

• Interviews were done 1 year into the implementation phase of the Collaborative.

• The data obtained were subjected to a thematic analysis.

Goal setting Data-driven action plans Continuous improvement cycles

Prevalent barriers • Navigating changes in personnel • Formulation of critical questions for instigating change and the adoption of methodology

Contact information: mexico@stjude.org Acknowledgements: Improvement teams and their coaches for their commendable contributions and diligent efforts

IMPORTANCE OF KARYOTYPE AND FISH CORRELATION FOR COMPREHENSIVE DIAGNOSIS OF PEDIATRIC PATIENTS WITH ACUTE LYMPHOBLASTIC LEUKEMIA: BRIDGE PROJECT MEXICO IN ALLIANCE WITH ST. JUDE COLLABORATION Netzi Rivera-Sanchez1 , Julio Alejandro Moreno-Serrano1 , Sergio Garay-Sanchez1 , Dinora Aguilar-Escobar1 , Berenice JarquinRamirez1 , Nataly Mercado2 , Naomi Echeandia-Abud3 , Pablo GonzálezMontalvo4 , Daniela Arce-Cabrera5 , Hugo Antonio RomoRubio6 , Margarita González Zamorano7 , Jose Loeza8 , María Valois Escamilla9 , Mayra López Ruiz10 , Daniela Covarrubias Zapata11, Dra. Laura García Segura12 , Selene Portillo13 , Mariana Reynoso Gutiérrez14 , Alma Mera González15 , Daniela CardenasPedraza16 , Norma Araceli Lopez Facundo17 , Lourdes Vega Vega1 , Paola Friedrich3 .

1Hospital Infantil Teleton de Oncologia,Querétaro, Mexico, 2Casa de la Amistad para Niños con Cáncer, México en Alianza con St. Jude, Ciudad De México, Mexico, 3St. Jude Children's Research Hospital, Global Pediatric Medicine, Memphis,

TN, United States of America, 4Hospital General "Dr. Agustin O'Horan", Mérida, México, 5Hospital Pediátrico de Sinaloa, Culiacan, Mexico, 6Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico, 7Hospital General con Especialidades "Juan María de Salvatierra", La Paz, Mexico, 8Centro Estatal de Cancerlogía, Xalapa, México, 9Hospital Infantil de Morelia "Eva Sámano de López Mateos", Morelia, Mexico, 10Hospital de Especialidades Pediátricas, Tuxtla Gutierrez, Mexico, 11Centro Estatal de Oncología "Dr. Luis González Francis", Campeche, Mexico, 12Hospital General de Celaya, Celaya, Mexico, 13Hospital Infantil de Especialidades Chihuahua, Chihuahua, Mexico, 14Hospital General de León, Leon Guanajuato, Mexico, 15Hospital del Niño DIF-Hidalgo, Pachuca, Mexico, 16Hospital para el Niño del Instituto Materno Infantil del Estado de México, Toluca, Mexico, 17Hospital Materno Infantil Del Instituto De Seguridad Social Del Estado De Mexico y Municipios, Toluca, Mexico.

RESULTS METHODS

BACKGROUND BACKGROUND In Mexico, approximately 7,000 children develop cancer each year. Of these, close to 40% are diagnosed with acute lymphoblastic leukemia (ALL) (1). Genetic markers are relevant for diagnostic and prognostic research of hematological malignancies. Fluorescent in situ Hybridization (FISH) and karyotype contribute to the diagnosis, staging, and prognosis of hematologic malignancies (2).

KARYOTYPE

FISH

Normal

22%

29%

28%

Normal

Altered

OBJECTIVES

71%

Altered

50% Without growth

The Bridge Project is a Mexico in Alliance with St. Jude (MAS) initiative that aims to improve access to a consensus derived diagnostic panel for children with suspected ALL in Mexico. We report the cytogenetic findings of karyotype and FISH panels and their importance in the diagnosis of Mexican patients with ALL.

Karyotype alterations

METHODS Bone marrow samples of children with suspected ALL from participating institutions were processed in the Molecular Genetics Laboratory of the Hospital Infantil Teletón de Oncología.

Cell cultures for karyotyping were performed and FISH technique used an embedded B/T-cell lymphoid panel (Table 1).

18

(A) Hyperdiploidy

16

(B) Complex Karyptype

14

(C) Non-common genetic alterations (D) TCF3::PBX1

12

(E) del(12)

%

10

(F) iAmp21 8 (G) BCR::ABL 6 (H) del(11) 4 (I) AFF1::MLL 2 A

B

C

E

D

F

G

H

(J) del(9)

J

I

0

FISH alterations

CYTOGENETIC PROCESS

Reception

Cell culture

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25

Harvest

(A) Gene gains 20

(B) ETV6::RUNX1 (C) iAMP21

Probe validation

Spreading

%

GTG banding

(D) TCF3::PBX1 (E) MLL

15

(F) BCR::ABL (G) TRA/D (H) del(9)

10

Microscope analisys

GTG banding

Hybridization

5

FISH panel LLA B

LLA T

BCR::ABL1

BCR::ABL1

MLL1

MLL1

ETV6::RUNX11

TRA/D1

TCF3::PBX11

CDKN2A1

A

B

C

D

E

F

G

H

0

CONCLUSIONS

TLX12 Image 1. Patient A Complex karyotype in ALL patient. 45,XY,i(5)(q10),-7,der(12)t(7;12)(q11.2;p11.2)

TLX32 Table 1. FISH panel ALL B/T. LSI probes from Vysis , Abott Molecular1 and Cytocell2

Complex karyotype (10.5%) and non-common genetic alterations (10.2%) findings in this study emphasize the karyotype diagnostic scope in pediatric ALL, being the only diagnostic methodology up to date capable of analyzing the whole genome within its resolution. FISH and karyotype findings are revealing an alternative distribution of genetic alterations in Mexican population, adding diagnostic and stratification value in childhood ALL.

Image 2. Patient A FISH probe using ETV6::RUNX1, showing ETV6 signal loss.

AKNOWLEDGMENTS

Image 3. Patient B iAMP21 detected by FISH using ETV6::RUNX1 probe

Casa de la Amistad para niños con Cáncer y México en Alianza con St. Jude (MAS).

COST-EFFECTIVNESS OF THE IMPLEMENTATION OF THE COLLABORATIVE “HORA DORADA” PROGRAM IN CHILDREN WITH CANCER AND FEBRILE NEUTROPENIA IN A HOSPITAL OF CENTRAL MEXICO NORMA ARACELI LOPEZ F 1, ANA B ALCANTARA G1, IVONNE ESTEBAN1, MARTHA CERVANTES J1, EDITH DE LA TORRE1, ELENA GAVIA1, NANCI REYES F1, CONCEPCION HERNANDEZ C1, ERIKA TINOCO1, YOLANDA TEJEDA1, ISIDORO TEJOCOTE1, CECILIA RODRIGUEZ1, ROBERTO SANCHEZ1; LILIAN DELGADO2 NAOMI ECHANDIA3 PAOLA FREDERIC 3 JAFET ARRIETA 4. 1HOSPITAL MATERNO INFANTIL DEL INSTITUTO DE SEGURIDAD SOCIAL DEL ESTADO DE MEXICO Y MUNICIPIOS, TOLUCA, MÉXICO 2 QUALITY PROYECTS MANAGER CASA DE LA AMISTAD PARA NIÑOS CON CÁNCER 3 ST JUDE RESEARCH HOSPITAL, DEPTO MEDICINA GLOBAL , 4.

INSTITUTE OF HEALTHCARE IMPROVEMENT

BACKGROUND BACKGROUND BACKGROUND

METHODS METHODS METHODS

Febrile neutropenia (FN) treatment exponentially increases the cost of care for children with cancer. In low- and mediumincome countries, it is vital to design strategies for resource optimization that simultaneously allow to reduce mortality, such as the implementation of the collaborative program St. Jude Global Mexico opportune administration of antibiotics before the first hour of medical care (“Hora Dorada”).

OBJECTIVES To determine the cost-efectiveness relationship of the collaborative program “Hora Dorada” in children with cancer and FN, attended at the pediatric emergency unit at the “Hospital Materno Infantil del ISSEMyM” in Toluca, Mexico.

A cost-efectiveness study was done comparing the approximated costs related to the treatment of children with FN who go to the emergency services unit before and after the implementation of St Jude Global ́s regional program “Hora Dorada”. The efficacy was defined as the percentage of patients with hospital discharge and no complications that require entry to the Intensive Care Unit (ICU), besides the percentage of deaths related to the febrile neutropenia event. An approximation of the global cost, average cost per patient and incremental cost-efectiveness was done in USA dollars.

Figure 2. Distribu@on of propor@ons. Approximated Global Cost derived from the care of pediatric pa@ents with cancer and febrile neutropenia, before and aGer the collabora@ve Golden Hour at the Maternal and Child Hospital of Issemym

Surgical and medical procedures

Table 1 Characteristics of children with cancer and febrile neutropenia before and after the implementation of the Golden Hour Collaborative, A Quality Improvement Program at the HOSPITAL MATERNO INFANTIL ISSEMYM TOLUCA, MÉXICO. Characteris*c Gender -Male -Female Age minimum-maximum (average) Diagnosis -Acute lymphoblastic leukaemia -Solid Tumor Treatment stage -Induction -Consolidation/intensification -Maintenance -other (relapse, radiotherapy etc.)

Pre-implementation N (%) 80 47(56%) 33(41.2%) 1-17 ( x̄ 7)

Post-implementation N (%) N 80 38(47%) 42(63 %) 1-17 (x̄ 7.9)

Imaging studies

0.2

20 (24%) 38 (45%) 24(28%) 2 ( 2%)

59(73% 21(27%) 7(8.7%) 34(40%) 30(22.5%) 9 (11.2%)

0.02 0.001 1 0.001 0.3

Absolute neutrophil count/mm3

0-846 x̄ 199

0-498 x̄ 237

0.45

43- 475 x 98min (3.8%)

19-65-x̄35 min (98%)

<0.001

Days of Stay

5-39 x 11.76

3x̄42(9.36)

0.01

Admission to UTIP -No -Yes

64(80%) 16(20%)

75(93.5%) 5(6.25%

0.01

40(50%) 20(25%) 14(17.5%) 6(7.5%)

67(83%) 7(8.7%) 6(9%) 0%

1.81%

13%

14.69%

29%

40%

63.17%

20%

0%

Before

0.01 0.5 0.3 0.05

38(47%) 14(18 % 9 (11.2%) 5 (16 %) 3(3%) 11(13.5)

9.36%

6%

Medicaments

0.09

5.31%

15%

Use of medical oxigen

0.3

4.64%

5%

Laboratory studies

6 (7.1%) 38(45.2 % 9 (11.2 %) 24 (28.6 %) 7 (7.1%)

Denouement -Home discharge without complications -Septic shock -Systemic inflammatory response -Death

12%

Days of hospital stay 49(58.3) 31(41.7)

1.02%

Transfusion of blood components

p

Infectious focus on admission -None -Upper Airway Infection -Pneumonia -Gastrointestinal -Other -Covid

Antibiotic Administration Interval <60 min

20%

20%

40%

60%

80%

A(er

RESULTS Eighty events per group were evaluated. There were no demographical, diagnosis, gender, or absolute neutrophils count diferences between both groups. 11.76 (5-39) vs 9.04 (3-42) hospitalization days were observed p=0.03. ICU entries were 12.5% vs 7.5% and death was 7.5% vs 0% before and after the program’s implementation. Approximated global costs were $8,720 (3753- 25,500) vs 2,532(558–11722) with and incremental cost-efectiveness of $1551/entry to ICU and $1,034/death avoided.

Table 2. Incremental cost-effectiveness analysis, considering different variables, before and after Golden Hour Quality Improvement intervention

<0.001 0.01 0.09

Average cost per patient

Item

CONCLUSIONS

efficacy

Number of Uncomplicated Cases or Admission to Intensive Care

Number of Admission to Pediatric Intensive Care

No. of Cases without Death

67 (83.5%)

75 (93.5%)

80 (100%)

40 (40%)

64 (80%)

74 (92%)

27

11

6

-$251.62 USD/uncomplicated case

-$1,132 USD/income to pediatric intensive care

-$1,166.33 USD/death avoided

$2,986.34 USD

Golden hour

(C2) $9974.4 Without hour

Golden

(C1) -$6,988

Difference

Incremental effectiveness

USD

USD cost-

CONCLUSIONS Clinical course and prognosis in children with cancer and febrile neutropenia are related to multiple factors. However, low-cost actions such as the timely administration of antibiotics are cost-effective and can lower the morbidity, mortality and the approximated costs, allowing resource optimization in a low-income country as Mexico.

EFFECTIVENESS IN THE IMPLEMENTATION OF “GOLDEN HOUR” PROJECT IN THE CHILDREN'S HOSPITAL OF TAMAULIPAS, MEXICO. Lilia Adriana Vollbrechtshausen-Castelan1 Edna Liliana Tamez-Gomez2 1Children´s Hospital of Tamaulipas, Pediatric Oncologist 2Children´s Hospital of Tamaulipas, Pediatric Hematologist

BACKGROUND BACKGROUND BACKGROUND

METHODS RESULTS METHODS

The Hospital Infantil de Tamaulipas is a third level pediatric hospital in the northeast of Mexico. It is the principal pediatric hospital attending pediatric oncology patients over the last 35 years in Tamaulipas.

Fifty seven events were evaluated. Some patients had more than 2 FN events, acute lymphoblastic leukemia was the principal diagnostic associated to FN. All patients had 2 blood cultures taken before 24 hours. All patients with FN were admitted to ER and 85.9% received first dose of broad spectrum antibiotic in less than 60 minutes. The election of antibiotic was according the institutional guide in 96% of the events.

Clinical effectiveness measures: % sepsis 5.2% (N=3).

Infection present on admission 29% (N=17), of them 5.2% (N=1) presented sepsis during the first 48 hours.

Critical interventions: 3.5% (N=2), transfer to ICU: 1.75% (N=1) mortality rate 1.4% (N=1)

The "Golden Hour" is an initiative to improve the quality of care in hemato-oncology patients with febrile neutropenia (FN) at the emergency room (ER). The project consist in the administration of first dose of antibiotic in less than 60 minutes, after the arrival at the ER, in order to decrease morbidity and mortality in pediatric hemato-oncology patients.

OBJECTIVE

To evaluate the effectiveness of the “Golden Hour" project in a pediatric hospital in Mexico.

PATIENTS WHO RECEIVED ANTIBIOTIC IN LESS THAN 60 MINUTES 1

METHODS

If the CBC reported severe neutropenia, broad-spectrum antibiotic IV was administered within 60 minutes of arrival. All patients had indicated 2 blood cultures.

Others studies were indicated according to the institutional guide of FN. All patients were followed up until they were discharged from hospital. The following clinical effectiveness parameters were measured: Percentages of sepsis, infection present on admission (POA), POA with sepsis, critical interventions, transfer to intensive care unit (ICU) and mortality rate.

85.90%

RESULTS RESULTS

rile neutropenia b e F 70.1%

Longitudinal study that includes 57 events of febrile neutropenia (FN) that attended the emergency room, between May 2019 to January 2023. All patients were under 18 years old. The criteria to start “Golden Hour" protocol were: reported fever at home or at the hospital and past history of received chemotherapy. The evaluation at ER consisted in: registration of date and time when fever started and complete blood count (CBC).

Infection present on admission 29.8%

1.75% 1

1

Critical interventions

Sepsis 5.2%

Transfer to ICU

1

3.5%

Mortality rate 1.4%

CONCLUSIONS

The “Golden Hour” project achieved a 85.9% goal.

Secondary to this, the indicators of clinical effectiveness are lower than those reported in the literature, highlighting a very low mortality rate. The implementation of this project in pediatric units for childhood cancer care is recommended.

REFERENCES: 1. Lehrnbecher T. et al. Guideline for the management of Fever an Neutropenia in Children with Cancer and Hematopoietic Stem-Cell Transplantation recipients: 2017 Update Guideline. Journal of Clinical Oncology 2017 35:18, 2082-2094.

2. Gonzalez M. et al. The Golden Hour: Sustainability and Clinical Outcomes of Adequate Time to Antibiotic Administration in Children with Cancer and Febrile Neutropenia in Northwestern Mexico. JCO Global Oncol 2021 7:659-670

Clinical impact of the "Golden Hour" in cancer patients with febrile neutropenia in a pediatric hospital in southeastern Mexico in association with St. Jude Simón-González, Perla Citlalli; Gutiérrez-Hernández, Juan Carlos; Quintana-García, Ellioth Alonso Federico; Ramírez-De Los Santos, José de Jesús; Alguien de HD; Gutiérrez-Lucatero, Silvia; González-Herrera María Dolores; Ross-Martínez, María del Carmen; Luévanos-García, Eduardo.

Hospital Regional de Alta Especialidad del Niño “Dr. Rodolfo Nieto Padrón”, Mexico, Tabasco, Villahermosa.

BACKGROUND BACKGROUND BACKGROUND

In Mexico, it is estimated that every year 7,000 children are diagnosed with cancer. Reported among the main causes of mortality for groups from 1 to 14 years of age. A main complication associated with cancer is Febrile Neutropenia (FN) secondary to chemotherapy, increasing events such as sepsis and being associated with a high rate of morbidity and mortality (every hour of delay decreases 7.6% in survival). Febrile neutropenia is the most frequent complication and the main reason for unplanned admission in pediatric patients with oncological diagnoses and who are being treated with antineoplastics, and can be potentially fatal.

OBJECTIVES Since November 2021, the Hospital Regional de Alta Especialidad del Niño “Dr. Rodolfo Nieto Padrón” (HRAE “Dr. RNP”) is part of “Mexico in Alliance with St. Jude” (MAS). The goal is to improve the care of the Febrile Hemato-Oncology Patients, from the detection and implementation of care protocols and thus reduce critical interventions. The goal of the "Golden Hour" (GH) is that 70% of pediatric hemato-oncology patients who come to the Emergency Department for fever receive the first dose of antibiotic in less than 60 minutes.

Other objectives were to identify the variation in clinical impact indicators, determine mortality in patients with oncological diagnoses and febrile neutropenia, and determine the impact in clinical deterioration events shown by this patients.

Of the total of 128 patients reviewed, 64 patients (50%) were male and 64 (50%) were female (Figure 1). The mean age was 8 years and 3 months. Only 33 patients (25%) went to the emergency room in the first 3 hours after the onset of fever; 74% did not do so for multiple reasons (Table 1).

Table 1. Time of arrival to receive medical attention from the onset of fever in cancer patients with febrile neutropenia.

Frequiency

Percentage

<3hrs.

33

25.8

>3hrs

95

74.2

Total

128

100

METHODS METHODS METHODS

At the HRAE “Dr. RNP" we carried out an observational, prospective, and cross-sectional study of 225 cancer patients who were admitted with FN from November 2021 to February 2023, comparing the time from registration to triage to antibiotic administration using the GH detection mechanisms before and after change interventions.

RESULTS RESULTS RESULTS

For GH the time of antibiotic administration was measured from the arrival to the triage, before and after the implementation of the change measures; with a baseline of 252 min that decreased to 30 min (improvement of 222 min, average of 50 min) as shown on Graph1, with 100% adherence to treatment and improvement in days of hospital stay from 8.48 to 7.47 days and a decrease in admissions to intensive care unit due to clinical deterioration events (Graph 2).

CONCLUSIONS CONCLUSIONS CONCLUSIONS

The percentage of patients to whom the “Golden Hour” protocol was applied (77%) increased by 226% since their institution. The use of amines, the need for ventilatory support, admission to the pediatric intensive care unit, sepsis and mortality were lower with the application of the “Golden Hour” protocol. The average, median, and mode days of hospital stay decrease when the antibiotic is applied within the first 60 seconds of the patient's arrival at the hospital.

In patients with childhood cancer from developing countries, timely and adequate treatment of febrile neutropenia is a fundamental aspect; Programs such as MAS help to implement these goals with improvement in the overall survival of patients, the current challenge being sustainability, adherence to internal regulations and continuous education.

1.

2.

3.

4.

Of the clinical indicators analyzed: 3.1% required management with amines, 2.3% needed ventilatory support, 1.6% were admitted to the intensive care unit and with overall mortality of 0.8%.

Torres, J. López, E. Rosanova, M. et al. Concenso Latinoaméricano de Neutropenia febril 2021. Revista chilena de infectología. 2021; 38 (6): 736-786.

González, M. Aristizabal, P. Loera, A. et al. The Golden Hour: Sustainability and Clinical Outcomes of Adequate Time to Antibiotic Administration in Children with Cancer and Febrile Neutropenia in Northwestern Mexico. JCO Global Oncology by American Society of Clinical Oncology. 2021; 7 (1): 659-670.

Todurkar, N. Trehan, A. Bansal, D. Time to antibiotic administration in children with febrile neutropenia: Report from a low middle-income country. Indian J Med Res. 2021; 154; 615-622.

Ornelas, M. Nuño, L. Loera, A. et al. The “Golden Hour”: a capacity-building initiative to decrease life-threating complications related to neutropenic fever in patients with hematologic malignancies in low- and middle-income countries. Blood Advances. 2018; 2 (1): 63-66

IMPLEMENTATION OF THE GOLDEN CODE IN AN IMSS CENTER PARTICIPATING IN THE 2ND MAS COLLABORATIVE. Dominguez Monasterio M.A. MD 1, Duran Francis 2, López Flores X. MD1, Jaimes Garcia Y. MD 1, Malvaez Estrada D.A. MD1, Venegas Esquivel G.A. MD 1 1 instituto Mexicano del Seguro Social, OncoCREAN, México, México.

2 Institute for Healthcare Improvement, Latin America, Boston, MA, United States of America

OBJECTIVES

BACKGROUND Fever and Neutropenia is the leading cause of admission due to complications associated with treatment; causing a mortality of 10-30%.

In HGR 251, an average of 40-60 cases per year are diagnosed, with 30 annual admissions for fever and neutropenia, causing 30% of deaths.

Achieving that ≥70% of febrile hemato-oncological patients (P-HOPf) who present to the emergency room receive the first dose of antibiotic in ≤60 minutes, reducing mortality associated with septic shock.

METHODS As part of the 2nd MAS Collaborative, our center uses a shared theory of change from which we select and test through PHEA cycles ideas to generate change in our context. During the last 12 months, we have been supported by a coach from the collaborative, who gave us guidance and support to analyze data and made adjustments to continuously improve existing processes.

Algorithm for treatment patients with fever and neutropenia.

SELECTION OF PHEA CYCLES

1

SITUATIONAL DIAGNOSIS

Personalized Intervention

2

- % Patients who received antibiotic in < 60 min

COACHING

3

TRAINING Training in quality models

Weekly & monthly coaching.

5

HEALTH EDUCATION

4 -

DIFFUSION

6

Neutropenia

Fever •

Single temperature of ≥ 38.3°C. (101ªF) or a temperature of > 38ªC (100.4ªF) sustained.

•

≤500/µL absolute neutrophil count (ANC).

•

Reference of the relative that the patient have fever.

•

≤ 1000/µL ANC with risk of decreasing to less than 500 in the next 48 hours*

•

Touch

•

Obtained through thermometry

*The ANC is predicted to continue to decline if the patienr is less than 10 days from the date of last chemotherapy.

Definition.

Patient and Family.

Healthcare Network

Stratification

Determine susceptibility to severe bacterial disease -

- Tumor: Leukemia in maintenance. Solid.

- Neutropenia; Installation in >10 days.

- No Septic Shock Data

-

Tumor: Acute lymphoblastic leukemia or acute myeloblastic induction phase, Lymphomas, Solid E-IV tumors; metastasis, relapse or progression.

Neutropenia; Installation in <7 days.

Hb <7, Plt < 50 000.

Septic Shock Facts (BP percentile <5); Altered alertness, shortness of breath.

Recent colonization or previous infection by MDR bacteria. < 1 year Malnutrition.

Empirical antibiotic scheme.

Risk

Low

Septic shock

Indications Vancomycin

High

Septic shock

Meropenem + Vancomycin

-Skin orSoft-tissue infection Suspected catheter-related infection - Pneumonia – Neuroinfection

Cefepime

Ceftazidima

Cefepime + Amikacina

- Hemodynamic instabiliy.

Ceftazidime + Amikacina

Piperacilin Tazobactam

Laboratory and Cabinet studies

RESULTS In a period from January 2022 to January 2023, 28 cases were attended, of which 18 cases met the objective (64%), in the first 6 months of implementation 8 cases were attended, only 50% met the goal; while the second half of the year increased to 70%, with a current median of 87.5%.

CONCLUSIONS The implementation of the Gold Code reduced admissions to the intensive care unit and mortality in PHO-f in our hospital, the probability of death was reduced by 84% acording to the RRR. To achieve these results, we tested ideas mainly focused on increasing clinical reliability, early identification of fever, ensuring effective access and availability of supplies in the patient care area. All the support and guidance provided by the collaborative were essential to achieve these results within the first year of work.

•

Hematic Biometrics

•

General urine test

•

PCR

•

CHEST X-RAY (RESPIRATORY SYMPTOMS)

•

URINE CULTURE

•

BLOOD

•

CENTRAL

•

PERIPHERAL

Table 1. Patient wiht fever and neutropenia Demographic and Clinical Characteristics Characteristics

No. Of Patients (N=28) ic 95% #

%

Age <3 3-15 >16

5 20 3

17.8 71.4 10.7

Sex Fem Male

16 12

57.1 42.8

Risk group Low High

15 13

53.5 46.4

Sepsis

3

11

Intensive theraphy

2

7

No. of deaths

1

3.5

- Relative Risk (RR) - Relative Risk Redution (RRR) - Absolute Risk Redution (ARR)

0.16 84 25

INCIDENCE OF SEPTIC SHOCK IN PEDIATRIC CANCER PATIENTS WITH FEBRILE NEUTROPENIA AFTER THE IMPLEMENTATION OF THE "GOLDEN HOUR" AT THE SALVATIERRA HOSPITAL. FAVIOLA CASTILLO FERNANDEZ DAVILA , CINDY AVILA VALDEZ, EDUARDO ALTAMIRANO HOSPITAL GENERAL CON ESPECIALIDADES JUAN MARIA DEL SALVATIERRA, ONCOLOGÍA PEDIÁTRICA, LA PAZ, BCS, MÉXICO

INTRODUCTION BACKGROUND BACKGROUND

RESULTS METHODS METHODS

Febrile neutropenia is a complication of cancer patients receiving chemotherapy.

The appearance of neutropenia associated with episodes of fever in cancer patients receiving chemotherapy is considered an emergency, it is vital that antibiotic therapy is started in the first hour after the onset of symptoms (golden hour), since it has been shown that the delay in the application of the antibiotic increases the risk of developing septic shock up to 60% and increases mortality by 7.6% .

In the period from November 2021 to January 2023, a total of 35 patients presented an episode of febrile neutropenia in which the golden hour was applied, of these patients 2 developed septic shock which corresponds to 5.7%.

PEDIATRIC CANCER PATIENTS WITH FEBRILE NEUTROPENIA

Hombres 15, 43%

OBJECTIVES

20, 57%

Mujeres

To know the percentage of pediatric cancer patients with febrile neutropenia who develop septic shock in our unit applying the "GOLDEN HOUR".

PATIENTS WHO DEVELOPED SEPTIC SHOCK 5.70%

INFECTION SEPTIC SHOCK

CONCLUSIONS CONCLUSIONS

METHODS

Data were collected from all hospitalized patients and new admissions who presented febrile neutropenia to whom the "GOLDEN HOUR" was applied from November 2021 to January 2023, subsequently those who developed septic shock were evaluated.

94.3%

CONCLUSIONS

The use of the GOLDEN HOUR significantly reduces the risk of septic shock, so it is important to publicize and apply this type of action to reduce morbidity and mortality in pediatric oncology patients.

12 de octubre A127 IMPLEMENTATION OF THE GOLDEN CODE IN AN IMSS CENTER PARTICIPATING IN THE 2ND MAS COLLABORATIVE. Primer Autor: Martha Alicia Domínguez Monasterio (Hospital General Regional no. 251 IMSS) A161 INCIDENCE OF SEPTIC SHOCK IN PEDIATRIC CANCER PATIENTS WITH FEBRILE NEUTROPENIA AFTER THE IMPLEMENTATION OF THE "GOLDEN HOUR" AT THE SALVATIERRA HOSPITAL Primer Autor: Andrea Castillo Fernández (Benemérito Hospital General con Especialidades "Juan María de Salvatierra") A171 RESULTS OF BETA 3 PEDIATRIC ONCOLOGY FACILITY INTEGRATED LOCAL EVALUATION (PROFILE) FROM THE HOSPITAL INFANTIL TELETON DE ONCOLOGÍA IN MÉXICO (HITO).

Primer Autor: Gabriela Escamilla Asian (Hospital Infantil Teletón de Oncología) A179 CONTEXTUAL FACTORS ASSOCIATED WITH THE SUCCESS OF THE GOLDEN HOUR MULTI-COUNTRY QUALITY IMPROVEMENT COLLABORATIVE Primer Autor: Paola Friedrich A185 IMPLEMENTING A HOSPITAL-BASED CANCER REGISTRY IN FIFTEEN MEXICO IN ALLIANCE WITH ST. JUDE (MAS) INSTITUTIONS: EXPERIENCE WITH SYNCHRONOUS MULTI-SITE IMPLEMENTATION Primer Autor: Karla Guerrero (México en Alianza con St. Jude) A237 IMPACT OF NURSING INTERVENTIONS ON THE EVOLUTION OF PATIENTS AT HIGH RISK OF CLINICAL DETERIORATION IN A HOSPITAL OF TOLUCA MEXICO Primer Autor: Norma Araceli López Facundo (Hospital Materno Infantil del Instituto de Seguridad Social del Estado de México y Municipios) A238 BUILDING LOCAL QUALITY IMPROVEMENT CAPACITY TO ACCELERATE OWNERSHIP OF QUALITY IMPROVEMENT PROJECTS: THE MEXICO IN ALLIANCE WITH ST. JUDE (MAS) EXPERIENCE Primer Autor: Paola Friedrich (México en Alianza con St. Jude) A241 IMPLEMENTATION OF THE QUALITY IMPROVEMENT MODEL FOR NURSING TRAINING IN THE TIMELY ADMINISTRATION OF ANTIBIOTICS TO HOSPITALIZED PEDIATRIC HEMATO-ONCOLOGIC PATIENTS WITH FEBRILE NEUTROPENIA Primer Autor: Cinthia Joallis Hernández González (Hospital Infantil Teletón de Oncología) 13

de octubre

USING QUALITY IMPROVEMENT COLLABORATIVES TO IMPROVE TIME TO ANTIBIOTIC THERAPY AMONG FEBRILE HEMATOLOGY-ONCOLOGY PATIENTS: EXPERIENCE FROM LATIN AMERICA Presentador: Paola Friedrich. Presentación oral. Horario: 10:50-12:20. Lugar Hall 205-207 A007 FEASIBILITY OF CENTRALIZED ACUTE LYMPHOBLASTIC LEUKEMIA TESTING IN MEXICO IN ALLIANCE WITH ST. JUDE (MAS) INST THROUGH A QUALITY IMPROVEMENT METHODOLOGY APPROACH Primer Autor: Nataly Mercado (México en Alianza con St. Jude) A019 IMPORTANCE OF KARYOTYPE AND FISH CORRELATION FOR COMPREHENSIVE DIAGNOSIS OF PEDIATRIC PATIENTS WITH ACUTE LYMPHOBLASTIC LEUKEMIA: BRIDGE PROJECT MEXICO IN ALLIANCE WITH ST. JUDE COLLABORATION. Primer Autor: Netzi Rivera (Hospital Infantil Teletón de Oncología) A137 COST-EFFECTIVNESS OF THE IMPLEMENTATION OF THE COLLABORATIVE “HORA DORADA” PROGRAM IN CHILDREN WITH CANCER AND FEBRILE NEUTROPENIA IN A HOSPITAL OF CENTRAL MEXICO. Primer Autor: Norma Araceli López Facundo (Hospital Materno Infantil del Instituto de Seguridad Social del Estado de México y Municipios) A143 CLINICAL IMPACT OF THE GOLDEN HOUR IN CANCER PATIENTS WITH FEBRILE NEUTROPENIA IN A PEDIATRIC HOSPITAL IN SOUTHEASTERN MEXICO IN ASSOCIATION WITH ST. JUDE Primer Autor: Ellioth Quintana García (Hospital de Alta Especialidad del Niño Dr. Rodolfo Nieto Padrón).

A171 EFFECTIVENESS IN THE IMPLEMENTATION OF “GOLDEN HOUR” PROJECT IN THE CHILDREN'S HOSPITAL OF TAMAULIPAS, MEXICO. Primer Autor: Lilia Adriana Vollbrechtshausen Castelán (Hospital Infantil de Tamaulipas)

14

de octubre

IMPLEMENTATION OF A QUALITY IMPROVEMENT PROGRAM IN THE TIMELY ADMINISTRATION OF ANTIBIOTICS IN HOSPITALIZED PEDIATRIC HEMATO-ONCOLOGY Presentador: Cinthia Joallis Hernández González (Hospital Infantil Teletón de Oncología). Discusión de poster. Horario 09:40-10:10. Lugar Exhibición