ABSTRACT
Advance care planning (ACP) has been shown to improve end-of-life care, yet uptake remains limited. Interventions aimed at increasing ACP uptake have often used a 'specialist ACP facilitator' model. The present qualitative study appraised the components of an ACP facilitator intervention comprising nurse-led patient screening and ACP discussions, as well as factors associated with the successful implementation of this model in primary care and acute hospital settings across rural and metropolitan Western Australia. Semistructured interviews were undertaken with 17 health professionals who were directly or indirectly involved in the facilitator ACP intervention among patients with severe respiratory disease. Additional process data (nurse facilitator role description, agreements with participating sites) were used to describe the nurse facilitator role. The interview data identified factors associated with successful implementation, including patient factors, health professional factors, ACP facilitator characteristics and the optimal settings for the intervention. The primary care setting was seen as most appropriate, and time limitations were a key consideration. Factors associated with successful implementation included trusting relationships between the nurse facilitator and referring doctor, as well as opportunities for meaningful encounters with patients. This study suggests a model of ACP nurse facilitation based in primary care may be an acceptable and effective method of increasing ACP uptake.
Subject(s)
Advance Care Planning , Attitude of Health Personnel , Interprofessional Relations , Nurse's Role/psychology , Nurse-Patient Relations , Nurses/psychology , Female , General Practitioners/psychology , Humans , Interviews as Topic , Male , Physician-Patient Relations , Primary Health Care , Professional-Patient Relations , Rural Population , Severe Acute Respiratory Syndrome , Terminal Care , Western AustraliaABSTRACT
BACKGROUND: Safety data for the multicomponent meningococcal group B vaccine (4CMenB) has so far been limited to experience from clinical trials and isolated local outbreaks. Since the UK is the first country to implement a nationwide routine immunisation programme with 4CMenB (at age 8 weeks, 16 weeks, and then 1 year), we aimed to assess the safety of 4CMenB in this setting. METHODS: In this prospective surveillance study, we assessed suspected adverse reactions of 4CMenB in children up to age 18 months reported in the UK Yellow Card Scheme and primary care records extracted from the Clinical Practice Research Datalink (CPRD). We proactively assessed reports of fever, local reactions, Kawasaki disease, seizures, and sudden death, and compared the number of spontaneous reports with the expected number of events based on background incidence and the number of children vaccinated. We also identified any unexpected adverse reactions and estimated compliance with subsequent doses of routine vaccinations. FINDINGS: From Sept 1, 2015, to May 31, 2017, approximately 1·29 million children aged 2-18 months received about a combined 3 million doses of 4CMenB. 902 reports of suspected adverse reactions were received through the UK Yellow Card Scheme, of which 366 (41%) were related to local reactions and 364 (40%) related to fever. The only unexpected finding was that 160 reports of local reactions described a persistent nodule at the site of injection, usually without other local symptoms. There were 55 (6%) reports of seizures, with an age-adjusted observed-to-expected ratio of 0·13 (95% CI 0·10-0·17). Ecological analyses found similar rates of seizures within 7 days of routine immunisation in the periods before and after 4CMenB introduction, with incidence rate ratios of 1·30 (95% CI 0·56-3·00) at age 2 months, 1·53 (0·49-4·74) at age 4 months, and 1·26 (0·69-2·32) at age 12 months. Of the 902 reports, three (<1%) were of Kawasaki disease (observed-to-expected ratio 1·40, 95% CI 0·29-4·08) and three (<1%) of sudden infant death syndrome within 3 days of vaccination in children aged 2-4 months (0·44, 0·12-1·14). Analysis of routine immunisations recorded in CPRD found that 11â602 (95·1%) of 12â199 children had received the second dose of 4CMenB by 26 weeks of age, 1793 (84·7%) of 2117 had received the third dose by 62 weeks of age, and 4CMenB introduction had not reduced compliance with doses of other routine vaccinations. INTERPRETATION: We found no significant safety concerns after widespread use of 4CMenB in UK infants, and the vaccine appears to have been well accepted by parents. However, it is important to continue monitoring the safety and long-term effect of the immunisation programme in the UK to further characterise the reported suspected adverse reactions. FUNDING: None.
