In the past, diabetes patients visiting
Singapore General Hospital’s (SGH)
Emergency Department with foot
ulcers were automatically admitted for
treatment by specialists.
While this ensured that serious
ulcers were quickly seen to, it meant that
those with minor wounds were ushered into
admission, taking up beds that could have
been given to those with more urgent needs.
Since 2022, however, only those with
an urgent need to be treated in hospital
were admitted while the others were
cared for in outpatient clinics under a new
structured programme called Rapid Access
FooT, or RAFT.
“We know that diabetic foot ulcer is
the tail end of end-stage diabetes, and
patients with ulcers have a major risk of
amputation,” said Professor Chong Tze Tec,
Senior Consultant and Head, Department
of Vascular Surgery, SGH, noting that 25
per cent of foot ulcer patients underwent
amputations a year. “I wanted to improve
the outcomes for diabetic foot ulcer
patients by giving them quick access to us
without having an impact on the already
tight hospital bed situation. So RAFT lets
us pay more attention to this group of
patients by giving them some extra special
help and attention through a fast track
to a specialised clinic.” Patients are usually
admitted for one to two days, sometimes
more if their condition requires
follow-up consultations with specialists,
wound care and dressing changes, and
antibiotic infusions.
Patients with end-stage diabetes are
prone to foot ulcers, which is an open
wound arising from poor blood circulation
or from a lack of sensation caused by nerve
damage. There is also a risk of the wound
becoming infected. A non-healing diabetic
ulcer can lead to the toe or foot needing to be
amputated. Immediate attention is therefore
necessary in patients with diabetic foot ulcers
at any stage to prevent amputations.
Patients coming to the RAFT clinic are
seen by a multidisciplinary team starting
with a vascular surgeon. They may then be
referred for a same-day ultrasound scan to
assess the blood supply to the leg. If there
are blockages, interventional radiologists
or other vascular surgeons are called in to
perform a revascularisation procedure to
restore blood flow to the leg. Nurses are on
hand to help with wound care and dressing.
A podiatrist may then provide customised
footwear to decrease pressure on the
wound while walking, thereby encouraging
wound healing. If diabetes control is poor,
an endocrinologist may get involved to
advise on adjusting the dose or changing
the medication. All these are seamlessly organised to happen within the same day or
the next business day.
While the RAFT clinic is a dedicated
service for diabetic patients, it does not turn
away non-diabetic patients with foot ulcers
should they be referred to the clinic. The
clinic currently receives referrals from the
SGH Emergency Department, as well as
from SingHealth polyclinics and a network
of general practitioners. It saw 54 patients
in 2022, which more than doubled to 128
patients in 2023.
More patients also avoided being
admitted. In 2022, only 16.7 per cent of
patients with diabetic foot ulcers needed
hospital admission, which dropped to
13.3 per cent in 2023. “These would have
been 100 per cent in the past as they
would all have been admitted. So, we saved
about 85 per cent of patients from being
admitted, but still gave them the full care
in an expedited fashion,” said Prof Chong.
This makes a big difference for diabetic
foot ulcer patients as they tend to be older
and may feel uncomfortable in an unfamiliar
environment. If hospitalised, communication
may be difficult due to the language barriers,
or they may simply be averse to hospitals.
“So, for those who are not actively infected
and are in no urgent risk for amputation,
the outpatient setting at the RAFT clinic is a
perfect fit,” added Prof Chong.
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