Department of Nursing, Institute of Health Sciences, Autonomous University of the State of Hidalgo, MexicoMexico
CUCS University Center for Health Sciences. Regional Public Health Research Institute. University of Guadalajara, MexicoMexico
Independent Researcher, former Professor in the Academic Area of Medicine and Masters in Public Health, Institute of Health Sciences, Autonomous University of the State of Hidalgo, MexicoMexico
Deparment of Medicine. Institute of Health Sciences, Autonomous University of the State of Hidalgo, MexicoMexico
Department of Pharmacy and Master’s Program in Public Health. Institute of Health Sciences, Autonomous University of the State of Hidalgo, MexicoMexico
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The “golden hour” is an international protocol, spearheaded by St. Jude Children’s Research Hospital, for the management of pediatric cancer patients (ALL). Objective: To evaluate the impact of an educational intervention on nursing staff regarding the implementation of the “golden hour” protocol for patients with acute lymphoblastic leukemia (ALL). Methodology : A quasi-experimental study was conducted based on a quality improvement model that employs a collaborative approach and continuous improvement methodology. The study was carried out in emergency departments at various hospitals among 110 nurses working different shifts and was conducted in three phases:Phase I: adaptation and validation of the measurement instrument to assess participants’ knowledge level before the educational intervention; Phase II: design and implementation of a training program through theoretical and practical sessions on the “Golden Hour” protocol; and Phase III: assessment of participants’ knowledge before and after training and evaluation of the educational program’s impact. Descriptive and comparative statistical analysis was performed using SPSS version 30.0. Results: Before the educational intervention, 71% of participants were at the low level, 25% at the medium level, and 4% at the high level. Following the educational intervention, the high level reached 89%, the medium level decreased to 5%, and the low level to 1%. Conclusions: Following the implementation of the educational intervention, a significant improvement was observed in knowledge, attitude, and practice regarding the “golden hour” protocol in the care of pediatric patients with Acute Lymphoblastic Leukemia (ALL). There was a significant increase in understanding of key timeframes, warning signs, and essential therapeutic measures during the first hour of care, as well as a greater ability to prioritize key interventions, such as the timely administration of antibiotics, monitoring of vital signs, and identification of early complications, such as septic shock.
Keywords: Educational intervention; Golden Hour, Febrile Neutropenia; Pediatric patients with ALL; Educationalintervention; GoldenHour; FebrileNeutropenia; PediatricpatientswithALL
AcuteLymphoblasticLeukemia(ALL)isthemostcommonmalignantneoplasmaffectingprimarilypediatric patients,posingasignificantchallengetohealthcare systemsduetoitshighincidenceandthecomplications associated with its treatment. It is one of the mostcommoncancersinchildren,accountingfor25% ofallchildhoodcancers.Itrepresentsbetween0.5% and3%ofallmalignantneoplasmsworldwide[1].This diseaseischaracterizedbytheabnormalproliferation anddifferentiationofaclonalpopulationoflymphoid cells, which generally results in impaired bone marrowfunctionandlocalinfiltration,leadingtouncontrolledproliferationofimmaturewhitebloodcellsin thebonemarrow(BM)andblood,aswellasinfiltration ofothertissuessuchastheliver,spleen,andlymph nodes,amongothers[1].
FeverandneutropeniaarecommonclinicalmanifestationsattheonsetofpediatricALL.Feverispresentin 45–52.8%ofcases,whileneutropeniaisdocumented in 60–68% of cases at the time of disease presentation.Thesimultaneousoccurrenceofthesesymptoms, knownasfebrileneutropenia(FN),isacommoncomplication in cancer patients receiving high-intensity chemotherapy,asisthecaseinthetreatmentofALL. Furthermore,itisaconditionthatoccursinchildren withALLatthetimeofdiagnosisandbeforetheyreceivecancertreatment[2].Theclinicalsignificanceof febrileneutropenialiesinthehighriskofseriousinfections,sepsis,andlife-threateningcomplicationsdue tothebody’sdiminishedimmuneresponse.
Earlyadministrationofbroad-spectrumantibioticshas beenassociatedwithasignificantreductioninmortalityandprogressiontomoresevereclinicalstates,makingresponsetimeakeyindicatorofqualityinmedical care[2].Accesstoeffectiveinterventionsandtheoptimaluseoftreatmentprotocolshaveincreasedsurvival ratesforpatientswithALLtoapproximately70–100%, primarilyduetoadecreaseinmortalityassociatedwith infectionsandrelapses[3].
In 2013, nurse Mitzy Romano Gorostieta designed a protocolincollaborationwiththemedicalandnursingstaffatTijuanaGeneralHospital[4].Thisprotocol, knownasthe“goldenhour,”playsafundamentalrole; itreferstotheperiodoftimethathealthcarepersonnel havetoassessapatient,whetherfebrileornon-febrile, withorwithoutneutropenia,duringwhichinterventions are critical to improving clinical outcomes. In 2018,theWHO,withthehelpofSt.JudeChildren’sResearchHospital,launchedaglobalpartnershipagainst childhoodcancer,whichofferstechnicalassistanceto help establish and maintain high-quality childhood vivalrateforchildrenwithcancerby2030,effectively doublingthecurrentrateandsavingonemillionmore livesoverthenextdecade[5].
Thegoalofthe“goldenhour”protocolistoensurethat allchildrenwithcancerwhopresenttotheemergency department(orequivalent)withafeverreceivetimely andeffectivetreatment,whichwouldreducetherisk ofseveretreatment-relatedinfectiouscomplications. Thisprotocolaimstoprovidepatient-centeredcareand optimizetreatment. ThespecificgoaloftheGolden Hourprotocolistoensurethatatleast70%offebrile hematologic-oncologypatients(P-HOPf)whopresent totheemergencydepartmentreceivetheirfirstdose ofantibioticswithin60minutesoftheinitialclinical evaluation[6].
Theeffectivenessofimplementingthe“goldenhour” protocolinpediatricpatientswithALLdependslargely onthecompetenceandknowledgeofthenursingstaff. Furthermore,ALLremainsasignificantchallengeinthe fieldofoncology,particularlyinpediatrictreatment, highlighting the importance of accurate risk stratificationandtargetedtherapiestoimproveclinicaloutcomes[7].
However,thereisevidencethattemporarynursingstaff mayfacechallengesinproperlyimplementingthisprotocolduetoalackofskills,knowledge,orexperience withit.
In this regard, timely and accurate care during the goldenhourcanaffectthesurvivalandqualityoflife ofpediatricpatientswithALL.Therefore,itiscrucialto evaluatetheeffectivenessofaneducationalprogram aimed at temporary nursing staff to improve the implementationoftheprotocol.
Consequently,thisstudyaimstoevaluatetheimpactof aneducationalinterventiononnursingstaffregarding theimplementationofthe“goldenhour”protocolfor patientswithacutelymphoblasticleukemia(ALL).
Thisstudyproposesthefollowingworkinghypotheses: thenullhypothesis,whichstatesthattheeducational interventiondoesnotalterthelevelofknowledge,and thealternativehypothesis,whichstatesthattheeducationalinterventionsignificantlyincreasesthelevel ofknowledge.
Studydesign. Aquasi-experimentalstudywasconducted.Themodelimplementedwasbasedoncontinuousimprovementstrategiesthatmadeitpossibleto evaluateinterventionsinrealtimeamongthenurses whoparticipatedinthestudy, usingstructuredindicators. Measurement became a key component for identifyingareasofopportunity,monitoringprogress, andsupportingclinicalandadministrativedecisionmaking.
Thestudypopulationconsistedofnursingprofessionalswhorotatedthroughtheemergencydepartments ofvarioushospitals.Thesamplecomprised110participantsselectedthroughnon-probabilisticconvenience sampling,basedonthefollowingcriteria:
• Nursing professionals assigned to or rotating throughtheemergencydepartment.
• Staffwithtechnical,bachelor’s,orspecialty-level academicqualifications.
• Staffworkingmorning,afternoon,night,andcumulativeshifts.
• Nursingstudents.
• Nursinginterns.
• Administrativestaffwithoutpatientcareduties.
• Participantswhochosetovoluntarilywithdraw fromthestudy.
• Questionnaires that were incomplete or containedinconsistentinformation.
Fortheanalysis,descriptivestatisticswerecalculated, aswellascomparativeanalysesbeforeandafterthe educationalintervention,usingtheStatisticalPackage fortheSocialSciences(SPSS),version30.0.
Thedevelopmentandimplementationofthisstrategy arebasedonthebioethicalprinciplesofbeneficence, nonmaleficence,justice,andrespectforautonomy.
Theinterventionseekstomaximizeclinicalbenefitby ensuringtimelycareandreducingrisksassociatedwith delaysintreatment.Likewise,itpromotesnonmaleficencebystandardizingevidence-basedpracticesthat reducethelikelihoodofadverseevents.
Regarding confidentiality, the data collected comes from medical records and is handled in accordance withstrictdataprotectioncriteria,preventingthedisclosureofpersonallyidentifiableinformation. Each participatinginstitutionisresponsibleforsafeguarding patientprivacyinaccordancewithcurrentregulations. Theprincipleofjusticeisreflectedintheimplementationofstrategiesaimedatimprovingthequalityof careinanequitablemanneracrossdifferenthospital settings.
Since this is a quality improvement initiative rather thananexperimentalresearchproject,thedataisused tostrengthencareprocesses,whilecomplyingatall timeswiththeapplicableregulatoryandethicalframeworks.
A total of 110 nursing professionals who rotated through the emergency department at various hospitalsparticipated.Ofthetotalparticipants,55.4% werefemaleand44.5%weremale.Intermsofage,the 28-to33-year-oldgroupwasthelargest.
Table1showsthesociodemographicdata(gender,age, andgroup)ofthestudypopulation.Thesampleisbalancedbygender,suggestingthattheresultsarenot biasedbythisfactor.
Table2showstheparticipants’educationallevels;62 ofthe110participantsheldabachelor’sdegree.
Toassessparticipants’levelofknowledgeregarding themanagementofcancerpatientsrequiringtimelyinterventionundertheGoldenHourprotocol,anadaptationwasmadeofthequestionnairetitled“Consensus ontheManagementofFebrileNeutropeniainPediatric OncohematologicalPatients”(CMFNPOP),whichinitiallyconsistedof11items;however,forthepurposes ofthisstudy,thequestionnairewasadaptedbyrestructuringitandincreasingthenumberofitemsfrom11 to15.
ThevaliditystagesoftheinstrumentareshowninTable3.Onceadaptedforthisstudy,apanelofexperts inpediatriconcologynursing,infectiousdiseases,and researchmethodologyreviewedtheinstrumenttoensuretheappropriateness,clarity,andrelevanceofthe items. Apilottestwasthenconductedwithasmall groupofprofessionalstoverifyitscomprehensibility andreliability,allowingforthenecessaryadjustments tobemadebeforeitsfinaladministration.
Theaspectsrelatedtosocialdesirability(responseinduction),clearinstructions,logicalsequence,andnumber of items reported a mean value below 0.8 on a scaleof1,asshowninTable4,highlightingareasfor
Table 2. EducationalLevelofParticipants
Technicaldegree 18 23.3 Bachelor’sdegree 62 18.4 Specialist 30 26.2 Total 110 100 18.3 0.02*
improvement.Thiswassupplementedbyqualitative observationsmadebytheexpertsontheitemsthey highlighted,whichwerethengroupedaccordingtothe questionnaire’sconceptualcomponents.
Consequently, the need to redesign the instrument basedonquestionsrelatedtothetopicwasidentified. Toaddressthecommentsthatweremade,questions 4,6,and10,whichprovidedduplicateinformationor showedalowcorrelationwithotheritems, wereredesigned. Consequently,theinternalconsistencyof theinstrumentachievedaCronbach’salphavalueof 0.83foratotalof11modifieditems.Thisadjustment allowedtheinstrumenttobebetterunderstoodand acceptedbythetargetpopulation,asshowninTable 5.
The results obtained in the previous stages demonstrated adequate internal consistency of the instrument, with a Cronbach’s alpha coefficient of 0.833 aftertheitemswererefinedandadjusted.Thisresult indicates adequate homogeneity among the items and a reliable measurement of the construct being assessed.Theexpertreviewidentifiedthattheitems were grouped into conceptual dimensions related to knowledge of febrile neutropenia, recognition of warningsigns,applicationoftheGoldenHourprotocol, andprioritynursinginterventions.Thesedimensions were consistent with the theoretical foundations underpinning the care of pediatric hematologiconcologic patients. A comprehensive evaluation of theinstrumentconfirmedtheappropriateness,clarity, and relevance of the items for measuring nursing staffknowledgeregardingthetimelymanagementof pediatricpatientswithacutelymphoblasticleukemia
Female 61 55.4 Male 49 44.5 Total 110 100 4.5 0.32
22 15 14.6 25 16 8.7 28 24 29.1 33 35 26.2 35 20 12.6 Total 110 100 11.2 0.04*
whorequirecareundertheGoldenHourprotocol.The findings support the instrument’s utility as a valid andreliabletoolforevaluatingeducationalprograms aimed at strengthening clinical competencies in pediatricemergencydepartmentsandoncologycare settings.
The educational intervention took place over six months,fromOctober2024toApril2025.Itconsisted of a structured training program comprising theoretical and practical sessions focused on the timely recognitionoffebrileneutropenia,theidentificationof warningsigns,theimplementationoftheGoldenHour protocol,theearlyadministrationofantibiotics,and thepreventionofcomplicationsassociatedwithsepsis. Activities included lectures, clinical case analyses, problem-solving exercises, group discussions, and simulationsofscenariosrelatedtothecareofpediatric hematology-oncologypatients. Anassessmenttool was administered before and after the program to measuretheparticipants’levelofknowledge.
Priortotheeducationalintervention,71%ofparticipantswereclassifiedashavingalowlevelofknowledge,25%ashavingamoderatelevel,and4%ashavingahighlevel.Followingtheeducationalintervention, therewasasignificantincreaseinthehighknowledge level, whichreached89%, whilethemoderatelevel decreasedto5%andthelowlevelto1%, asshown inTable4. Theeducationalinterventionnotonlyallowedfortheevaluationofquantitativeresultsbutalso facilitatedlearning.
Real-timedataanalysisfacilitatedtheidentificationof barriers,theimplementationofchanges,andtheevaluationoftheeffectivenessofthe“goldenhour”protocol. Thisstudyprovidedmeasurement,analysis,andaction resultsthatarefundamentaltoachievingsustainable improvementsforpatientswithALLwhorequiretimely
Stage1 Construct validity of the instru- 2judgesspecializinginpediatrics,2ingen- ConstructValidity ment,assessedbyexpertjudges eralmedicine,3inoncohematology,2inon-
Stage2 Validationoftheinstrument’sre- 200nurses ReliabilityAnalysis liability ReliabilityAnalysis Reliability validity of the designed instrument (including judges’observations) Stage3 Definition of components (reli- Exploratory and ableCronbach’salpha) confirmatory factor analysisFinal reliabilityanalysis.
Table 4. Cronbach’salphavaluesandreliabilitycoefficientsforthemeasurementinstrument
0.742 0.699
Table 5. ItemDescriptiveStatistics
1 1.87 0.75 200 2 2.10 0.83 200 3 2.37 0.82 200 4 1.14 0.47 200 5 2.14 0.75 200 7 1.27 0.50 200 8 2.13 0.85 200 9 2.09 0.68 200 10 2.27 0.64 200 11 1.75 0.82 200
care.Furthermore,theintegrationofdatafrommultipleinstitutionsenabledthegenerationoflarge-scale evidence,strengtheningdecision-makingandpromotingtheadoptionofbestpracticesinvariouscontexts, asshowninTable6.
Asignificantincreaseinknowledgewasobservedfollowingtheintervention(p<0.001).
Theresultssuggestthattheeducationalintervention significantlystrengthenedthenursingstaff’sabilityto identifycriticalelementsoftheGoldenHourprotocol, includingtheearlyrecognitionofwarningsigns,the prioritizationofcare,andthetimelyadministrationof therapeuticinterventions.
Furthermore,theimplementationofcontinuousimprovementstrategiesmadeitpossibletoidentifyareas forimprovementincareprocesses,promotingthestandardizationofclinicalpracticesaimedatthesafeand timelycareofpediatrichematology-oncologypatients.
cologynursing,and2educationprofessors.
re- 200nurses
Theresultsofthisstudydemonstratethatastructured educational intervention significantly improved nursingstaffknowledgeregardingtheimplementation of the “golden hour” protocol for patients with ALL. Thefindingshighlighttheimportanceofimplementing structured assessment strategies to improve the qualityofcareforpediatricpatientswithcancer[9]. The systematic review published in Healthcare identified that continuing education is an essential componentformaintainingprofessionalcompetence in oncology nursing, as it improves clinical performance,strengthenspatientsafety,andfacilitatesthe incorporation of evidence-based recommendations. These findings support the increase in knowledge documented in the present study and suggest that continuing education should be considered an essential element in institutional quality programs [10].
AstudyconductedatateachinghospitalinsouthwesternBrazildemonstratedthattheimplementationof a“GoldenHour”protocoldependedonanorganized processthatincludedasituationalassessment,participatoryprotocoldevelopment,trainingsessions,protocolimplementation,andcontinuousmonitoringof outcomes. Theauthorsemphasizethattrainingwas themainfacilitatorfortheprotocol’simplementation; theyalsoconcludedthatcontinuingeducationisindispensableforconsolidatingchangesinclinicalpractice andachievingbetteroutcomes[11].
In addition, in 2022, the St. Jude Global Mexico Regional Program and the Institute for Healthcare Improvement(IHI),throughthe“GoldenHour”initiative,
1 15.74 12.75 2 15.51 12.33 3 15.24 13.53 4 15.77 12.58 5 15.57 12.99 6 15.78 13.25 7 15.58 13.19 8 15.86 13.79 9 16.21 14.14 10 15.57 12.44 11 15.85 12.31
Table 7. LevelofKnowledgeBeforeandAftertheEducationalIntervention
High 4% Medium 25% Low 71% Total 100%
providedtrainingonqualityimprovementmethods, tools,andskillsviavirtualandin-personworkshops called“LearningSessions,”implementedincollaborationwithhospitalsinMexicoandlaterexpandedto varioushospitalsthroughoutLatinAmerica.Thanksto theseinterventions,thepercentageofpediatriccancerpatientswithfeverwhoreceivedthefirstdoseof antibioticswithinthefirst60minutesincreasedfrom 47%to79%,whiletheincidenceofsepsisdecreased from16%to6%,resultinginasignificantincreasein thelevelofknowledgeregardingtheapplicationofthe “GoldenHour”protocolinpediatricpatientswithALL. Thefindingsofthisstudysupporttheconclusionthat educationalinterventionsareafundamentalcomponentoftheeffectiveimplementationofthe“Golden Hour”protocol,demonstratingthattrainingandtheorganizationofcareprocessescanleadtobetterclinical outcomes[12,13].
Similarly,astudyconductedatTijuanaGeneralHospitalimplementedathree-phasemultimodalimprovementstrategy(execution,consolidation,andsustainability)called“GoldenHour”toreducethetimetoantibioticadministrationinpediatriconcologypatients withfebrileneutropenia,resultinginincreasedcompliance with the indicator for antibiotic administrationwithin60minutesandasignificantreductionin episodesofsepsisandotherinfectiouscomplications. Thishighlightstheimportanceofongoingtrainingfor healthcarepersonnel,coupledwithorganizationalinterventionsandstandardizedprotocols,whichisan 1.0mm
.528 .702 .530 .700 .418 .738 .559 .797 .480 .725 .307 .711 .230 .724 .143 .746 .150 .733 .157 .745 .147 .754
89% 5% 1% 100% 0.005
indispensableelementforimprovingthequalityofcare [14].
Theseresultshighlighttheimportanceandnecessity ofongoingeducationalprograms,aswellasthestandardizationofprotocolstooptimizecareforpediatric patientswithALLandotheroncologicalconditions[15]. However,implementationfaceschallengesrelatedto variabilityinresources,organizationalculture,andthe ongoingtrainingofnursingstaff[16].
Finally,itwouldbenecessarytoconsidertherecommendationofpsychologicalinterventionsforthemanagementofpsychoneuroimmunologicalmarkersofpediatriccancer[17].
The implementation of an educational intervention based on quality indicators made it possible to optimize care processes for pediatric hematologiconcologypatientswithALL.
Beforetheprogram,knowledgeoftheprotocolwaslimited,andonlyasmallpercentageofstaffcorrectlyidentifiedthecriticalstepsininitialmanagement.However, followingtheintervention,asignificantincreasewas observed,revealingarelationshipbetweenthetimelinessoftreatmentandareductioninadverseevents, suchasthedevelopmentofsepsis,theneedforcritical interventions,andpatientadmissiontointensivecare units.
Thisstudydemonstratesthattargetedcontinuingeducationiskeytostrengtheningclinicalcompetencies, particularlyamongtemporarystaffwhofrequentlyrotatethroughdepartments,therebyhelpingtoreduce clinicalcomplicationsandenhancequalityofcareand patientsafety.
Theauthorsdeclarethatthereisnoconflictofinterest regardingthepublicationofthisarticle.