In autumn 2022 the A.R.C.O. project (Remote Assistance to Caregivers in Oncology) came to an end. It was carried out within the Regina Elena National Cancer Institute – IRE thanks to the PRISM-E tender of the POR F.E.S.R. 2014/2020.
The project, which lasted two years and was developed together with Doxea srl and BEPS Engineering srl, involved the testing of a technological and organizational infrastructure for remote assistance to caregivers of cancer patients with medium- and long-term venous access.
Oncology patients and PICCs
Many treatments for cancer patients involve taking intravenous medication through a PICC, whose implant is indicated for the administration of prolonged or repeated cycles of chemotherapy, antibiotics or for parenteral nutrition.
The PICC (Peripherally Inserted Central Catheter) is a central venous catheter inserted peripherally at arm height. It is a small silicone tube that, once inserted with the aid of an ultrasound guide, reaches the superior vena cava in the chest and allows the administration of medication. The PICC is a long-term venous system that can remain in place for up to 6 months.
The use of this device reduces the risk of infection and thrombosis and helps to safeguard the patient’s venous asset, which is already stressed by repeated blood draws and other treatments that damage the vascular bed. Moreover, the PICC allows freedom of movement for the patient and has the advantage of being a permitted treatment in both hospital and home settings.
In spite of these advantages, wearers of this device must undergo periodic medication to prevent possible complications.
In order to implant and manage PICCs, there is a dedicated outpatient clinic (IGAV) in the IFOs, of which the IRE is a part, where specialized nurses implant and ‘maintain’ venous catheters. The ‘maintenance’ operations, consisting of medication and dressing, are estimated to be around 10,000 per year in the IFO alone. This number corresponds to the same number of patients who, on a weekly basis, have to go to the outpatient clinic for a procedure that takes about 15 minutes.
Difficulties for patients in PICC management
After analysing the characteristics of the patients treated by the IGAV clinic, some critical issues emerged, which are also dictated by the lack of dedicated outpatient clinics in the area:
- almost 50% of patients live outside the province, and the travel time to get to the clinic is on average more than 2 hours;
- for working patients (one third of the followed up patients) travelling to the clinic represents a financial commitment;
- many patients need to be accompanied by a family member or friend, who in turn must take specific leave (law 104/92) and organize their own schedule.
These considerations have led to the development of a project that would take into account the needs of the patient in order to improve not only their adherence to therapy, but also their quality of life.
Project goals
Although the washing and dressing of the PICC are delicate activities, no particularly complex manual skills are required. Operations are now highly procedural in order to avoid complications (such as sepsis, catheter dislodgement/occlusion or thrombosis) and require simple disposable equipment. Finally, there are no contraindications to performing them as quickly and effectively as at the patient’s home.
These considerations, combined with the critical factors listed above, have led to the establishment of the following objectives:
- reducing the need for outpatient services;
- reducing the related direct and indirect costs;
- improving patient adherence to therapy;
- improving the patient’s quality of life.
To achieve these objectives, it was decided to work on the empowerment of caregivers by devising a solution that would allow them to safely perform a number of procedures which were traditionally reserved for nurses, such as washing and dressing catheters.
The A.R.C.O. solution
Although the available evidence shows that the management of venous accesses at home by a (properly trained) caregiver does not carry a higher clinical risk profile than dressing in hospital, caregivers are reluctant to perform these procedures themselves. The distance and the sense of isolation from the care centre are in fact a source of uncertainty and stress, which makes caregivers and patients desist from performing these operations at home.
In order to overcome this resistance, it was decided to invest in a telemedicine project by creating an ad hoc technological and organizational infrastructure.
Point-of-care
The designed solution was a point-of-care consisting of an automated tripod that allows remote supervision and audio-video support. The caregiver can therefore receive assistance from a specialized operation centre that can identify and manage any unforeseen events in real-time.
The easy-to-use software allows the healthcare worker to control the operations of the caregiver who, in turn, can carry out all the procedures hands-free while respecting the required hygiene standards.
A new organizational model
The introduction of this point-of-care has also led to organizational innovation, consisting in the modelling and structuring of a new range of services, with the related definition of protocols, procedures, guidelines, operating instructions, training modules and auxiliary functions (web tools) for healthcare professionals and caregivers.
In fact, it is important to consider that the introduction of eHealth in a healthcare facility redefines the traditional way of understanding care processes by questioning already established practices and roles. Hence, there is the need to consider both the technological and organizational dimensions together from an HTA perspective.
Advantages
The advantages of the A.R.C.O. project are many due to all those who are involved (patients, caregivers and healthcare facilities):
- increased confidence of caregivers, with consequent willingness to perform PICC dressing and washing procedures at home;
- reduction of hidden systemic costs such as transport, downtime, lost caregiver and patient working hours;
- increased patients’ adherence to treatment;
- reduction of the stress generated in patients to go to the hospital, with a consequent improvement in the quality of life;
- optimization of the deployment of dedicated nursing staff for venous access management;
- possibility of reusing the devices and the telematic infrastructure in different contexts of care.
“All patients were very satisfied. Being able to stay at home and arrange more convenient times without feeling less cared for by the hospital staff was very much appreciated, and they were reluctant to return to the outpatient clinic for dressing.“
Dr. Paolo Basili – Nursing Coordinator of the Outpatient Clinic and DH of Pain Therapy, I.G.A.V. – Regina Elena National Cancer Institute
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