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新加坡心理衛生學院SARS疫情對台灣精神醫療的省思

林朝誠

玉里榮民醫院精神科主治醫師

台灣心靈健康資訊協會理事長

心靈園地總編輯

新加坡在連續15天未有新的SARS個案的佳績時，心理衛生學院(Institute of Mental Health)卻暴發SARS集體感染，這個事件值得台灣衛生單位及各精神醫療院所警惕，茲將所搜集到的資料翻譯整理，按時間順序、發生的事件及處理的方式列於下表之疫情大事記，最後並附上相關之中英文報導資料，給大家參考。

     新加坡心理衛生學院SARS疫情大事記

   心理衛生學院簡介

      l在七個點設門診

      l特別門診及方案包括Stress and Anxiety Clinic, Mood Disorder Clinic, Eating Disorders

         Clinic, Sleep Disorder Clinic, Sexual Dysfunction Clinic, Early Psychosis Intervention

          Programme (EPIP) and Community Addictions Management Programme (CAMP).

      l社區支持方案包括 community psychiatric nursing teams, pre-discharge patient 

         education, family education, Community Addictions Management Programme and Early 

         Psychosis  Intervention Programme.

      l病人通常都是長期住院病人，可能住上几個月，甚至是几年。這些病人跟社區的

         接觸也很少。因此，雖然目前院內住著1800多名病人，不過每天入院、出院的病

         人人數卻不多

    探討

        史，未被視為SARS個案處理，讓SARS病毒有機會散播；現階段若有病患發燒是

        否應先轉到隔離病房較安全，至少不要讓感染範圍擴大。

        的死角，台灣目前已有一名精神病患感染SARS，會不會有類似新加坡大規模感

        染情形出現呢？如何防範呢？

        在我的‘雷達’上，在策略上，我犯了一個錯誤。我以為，它不會帶來多大的問

        題，結果不然，但目前也不是作無謂的追究的時候，而是必須解決眼前的問題。

        會在短期內解除醫院訪客禁令，以保障整個社區的安全。

        客方面的追查工作，值得各精神醫療院所參考，另外也須控制會診、轉診及請假

        等措施。

        神病患三週後輪由乙病房收新個案三週，甲病房病患若在此三週內無人發燒再轉

        到其它精神科病房，再輪由甲病房新收個案，以此類推，直到台灣SARS疫情被

        控制住；此二病房的工作人員為單獨的人力，不與其它病房共用。這樣可以預防

        萬一真的有收到SARS個案，只有1到2個病房的病人及少數醫護人要隔離，而不

        用像心理衛生學院一樣要隔離1800多名病人及1600多名工作人員。

        帶口罩，會讓這個措施難以落實。

   參考資料

    l Plans to use IMH as halfway house for non-SARS discharged patients shelved

    lIMH staff move into temporary isolation quarters at Woodlands

    l聯合早報(新加坡) 

    以下為相關報導

   2003/05/15

   l 心理衛生學院醫護人員轉住酒店隔離 

       心理衛生學院昨天改變讓醫護人員到兀蘭一座組屋隔離的作法，讓他們分批住進几家酒店進行隔離。衛生部昨晚發表的文告說，該院的124名醫護人員前晚原本已遷入兀蘭的組屋，不過昨天卻陸續安排住進酒店。這是心理衛生學院為了提高醫護人員的士氣，并確保他們的福利與起居得到良好的照顧，而做出的特別安排。衛生部表示，這些住在酒店的醫護人員都必須留在自己的房內，不允許有訪客，也不可使用酒店的設施。 當局強調，所有被安排入住酒店的醫護人員目前的健康狀況都良好，不會傳染疾病。他們感染沙斯的可能性也很低，并且每天仍舊會回到心理衛生學院上班，繼續照顧病人。其中一批為數約150名的醫務人員，昨晚8時左右乘了4輛冷氣旅行巴士到達一家酒店。他們有些戴上口罩，有的顯露倦容，有的臉露笑容。這些旅行車是從兀蘭組屋區將他們接送到酒店。

     l 集體發燒事件一旦控制 心理衛生學院將作為“中途”隔離站 

        心理衛生學院一旦能將集體發燒的事件控制下來，抗炎作戰部隊將會開始利用院內的300多張空置著的床位，作為非沙斯病人在轉到療養院之前的隔離設施，以確保沙斯病毒不會有機會走入社區。

          有更多人出現發燒症狀，被送入陳篤生醫院接受觀察。 昨天送院觀察的是3名病人和7名醫護人員，這使留院觀察者從原本的27人，增加到37人。

　　另一方面，發燒的病人與醫護人員也不再局限于64和65號病房。另外兩個病房，35和50B，也出現了集體發燒的情況。 衛生部昨晚發表的最新疫情匯報指出，所有從心理衛生學院送往陳篤生醫院接受觀察的病人和醫護人員，至今無人出院。由于心理衛生學院的門診服務已全面關閉，衛生部因此也為需要復診的病人，做出了另外的安排。

        這主要是因為心理衛生學院的病人通常都是長期住院病人，可能住上几個月，甚至是几年。這些病人跟社區的接觸也很少。因此，雖然目前院內住著1800多名病人，不過每天入院、出院的病人人數卻不多，不像中央醫院那樣每天可能有一兩百人。

        抗炎作戰部隊指揮官許文遠說：“坦白地說，心理衛生學院目前的確沒有在我的‘雷達’上，在策略上，我犯了一個錯誤。我以為，它不會帶來多大的問題，結果不然，但目前也不是作無謂的追究的時候，而是必須解決眼前的問題。”

        宏茂橋醫院已從上個月17日起率先成為本地首個“中途之家”，至今已有104名病人通過了隔離觀察期，而轉到了療養院或回到家中。

　　這類“中途之家”的目的是要讓那些需要從公共醫院轉入療養院或回家修養的病人，先接受10天隔離觀察，以確保沒有出現沙斯症狀。不過，由于宏茂橋醫院的規模較小，所騰出的隔離床位只有65張，因此，抗炎作戰部隊認為，仍有必要動用到心理衛生學院的床位和設施。

  l醫院訪客禁令 短期內不會解除

        以目前的情況看來，最容易受到感染的地方仍然是醫院。因此許文遠重申，將不會在短期內解除醫院訪客禁令，以保障整個社區的安全。

 2003/05/14

 l心理衛生學院員工 漏夜大搬遷(2003/05/14)

心理衛生學院昨晚展開漏夜大搬遷，1642名醫護人員和職工，分批住進隔離住所。衛生部在昨晚的記者會上宣布，心理衛生學院可能出現新一波的沙斯疫情后，當局立刻采取預防措施，將學院的醫護人員和職工，安排住進兀蘭和裕廊的隔離住所10天。受隔離的人多達1642人，包括1342名全職醫護人員和職工，以及300名合約員工。他們在住進隔離住所后，將不准回家，但每天仍會到心理衛生學院上班。

每天照常上下班﹒專車接送供三餐

　　心理衛生學院的1642名醫護人員和職工，在住進隔離住所后，將會有各自的房間，每天有三餐供應，以及專車接送他們上下班。

　　位于兀蘭的隔離住所都是空置的組屋，分別有三房式和四房式的單位。而裕廊的隔離住所是一些舊的武裝部隊住所。

　　當局會盡量安排每一個人住在單獨的房間里，房里有床褥、風扇和其他日常必需品，每天供應三餐給他們。

　　這些被安排住進隔離住所的人，健康情況良好，他們將照常上班，不過當局會安排專車接送他們往返心理衛生學院和隔離住所，他們除了在10天內不准回家外，在休息日也不可以離開隔離住所。此外，他們每天必須測量體溫三次。

《新明日報》

l

心理衛生醫院30病人護士集體發燒
新加坡可能發生新一波疫情

　　本地的沙斯疫情昨天出現新變數。心理衛生學院（前稱板橋醫院）似乎出現了新一波的沙斯疫情。

　　心理衛生學院三天前發生30名病人和護士集體發燒的情況，衛生部為了安全起見，已將這些病例當作是沙斯引起的病例來處理。

　　心理衛生學院從即日起將全面關閉門診和緊急部門服務，并且不再接受新的病人，同時不允許目前約1800名留院的病人出院。

　　與此同時，為了進一步防范，院方已經安排所有1342名全職醫護人員和職工，以及300名合約員工住進設在兀蘭和裕廊的隔離住所，并在接下來的10天不准回家。這些醫護人員和員工每天都會有專車接送往返醫院，照常工作。

　　心理衛生學院的24名病人和6名護士是在星期天和星期一，出現集體發燒的症狀。最早開始發燒的病人，其實是在本月7日，接著在星期天，3名護士也出現發燒症狀。

同一病房23人發燒

　　其中，23名病人來自64號病房，另一名病人則屬于65號病房。這兩個病房的病人都是60歲以上、患有慢性精神疾病的老病人，不過卻沒有其他多重疾病。

　　目前，除了3名護士因為只有輕微發燒，由醫生給了病假在家養病外，其余27人都留院陳篤生醫院接受觀察。兩名曾在這兩個病房內值勤的醫生昨天也送到陳篤生醫院接受檢查。

　　衛生部長林勛強昨晚召開記者會時指出，當局目前正在追查可能導致感染的因素。他表示，當局非常重視這次事件，并且會以沙斯病例來認真處理。

　　林勛強說：“在某些方面，這次集體發燒事件同中央醫院的疫情非常相似。不同的地方是，我們已在上個月29日禁止人們到醫院探訪病人，因此，可大大減少訪客方面的追查工作。

已有三四個病例 肺部已受到感染

　　“而且這一次，大家也較有准備，懂得如何采取更好的防范，減少醫護人員之間的傳染，以及傳染給家人和社區的機會。我們應能很好地遏制這次的傳染情況。”

　　衛生部醫藥總監陳祝全教授昨晚表示，大家當然都希望這波傳染不會演變成最糟的情況。“不過，由于集體受感染的人數相當多，因此，由別的疾病所導致的可能性不高。我們有必要認真處理這些病例。”

　　傳染病中心臨床主任梁玉心醫生也指出，已有三四個病例的肺部X光出現了影子，顯示肺部已經受到感染。不過，究竟是不是沙斯病毒所導致的，則有待進一步的化驗結果。

　　心理衛生學院的300多名醫護人員和員工昨晚已經開始遷入在兀蘭的隔離住所。其余的醫護人員和員工則將于今天完成搬遷工作。設在兀蘭的隔離住所都是空置的新組屋，而裕廊的隔離住所則是一些舊的武裝部隊住所。

Institute of Mental Health (IMH): in Hougang, Singapore

• IMH/WH is licensed as a 2,542 bed specialized care hospital offering multi-faceted psychiatric treatment services.

• a satellite network of seven outpatient clinics

• offers psychiatric treatment, rehabilitation and counseling services that are designed to meet the special needs of 3 age groups, namely, children & adolescents, adults and the elderly

• there are specialized clinics and programmes such as the Stress and Anxiety Clinic, Mood Disorder Clinic, Eating Disorders Clinic, Sleep Disorder Clinic, Sexual Dysfunction Clinic, Early Psychosis Intervention Programme (EPIP) and Community Addictions Management Programme (CAMP).

• has 3 Day Centres managed by the Occupational Therapy Department

• community support programmes include community psychiatric nursing teams, pre-discharge patient education, family education, Community Addictions Management Programme and Early Psychosis Intervention Programme

SARS News:

7 May 2003

The first case at the IMH surfaced on May 7. A patient in Ward 64, which houses 96 chronically-ill mental patients above the age of 60, came down with a fever.

He was moved to a 'fever ward' and nothing seemed amiss until Sunday, when three nurses also became feverish. They were taken to TTSH, which sent them home on medical leave as they had a low-grade fever but no history of contact with a Sars patient.

11-12 May 2003

But by Monday, 23 patients from Ward 64 and one from Ward 65 were running temperatures. And so were another three nurses.

Twenty-four elderly patients and six nurses at the Institute of Mental Health in Hougang are down with fever. All the patients and three of the nurses have been warded at Tan Tock Seng Hospital. The other three nurses are being quarantined at home.

12 May 2003

Another 1,600 staff members can continue working, but they will be moved temporarily into isolation accommodation in Woodlands and Jurong.

The first of the staff were taken by bus last night to their new lodgings, where they will stay for the next 10 days.

13 May 2003

They were all from two wards. Two doctors were also sent to TTSH to be checked.

Another 1,600 staff members can continue working, but they will be moved temporarily into isolation accommodation in Woodlands and Jurong, where they will stay for the next 10 days. Although they are all well, the hospital's senior management and staff decided that the move will allow for close monitoring of everyone, ensure their well-being and minimise contact with their loved ones and the community.

Each person will have his own room, which will have a mattress, fan and other basic necessities. Meals will be provided and buses will ferry them to and from work each day. Their temperatures will also be monitored three times a day.

These precautions are also being taken: None of the remaining 1,800 patients will be discharged for now, there will be no new admissions and the hospital has closed its accident and emergency, and outpatient services.

There will also be no movements of patients and staff across wards, and no referrals of patients to other hospitals. Urgent medical problems will be managed by TTSH.

Health Minister Lim Hng Kiang: the priority now was to stop the infection spreading to the community. 'For this to be done, it has to be done for all,' he said.

A cluster of 24 patients and 6 nurses of the Institute of Mental Health have developed fever which was detected over the two-day period from 11th to 12th May. Of these, 23 patients were from Ward 64 and 1 from ward 65. They have been referred to TTSH for further assessment. All of them, except three nurses who were given medical leave, have been warded for observation. Two doctors who had worked in the same wards were referred to TTSH for assessment today. This large cluster of cases has to be assumed to be due to SARS until proven otherwise. Epidemiological studies are underway to try to identify a possible source of infection.

Active contact tracing is being carried out. All patients who were discharged from IMH from 23rd April till 2 May will be recalled for medical review at TTSH. For those discharged from 3rd May onwards, they will be put under Home Quarantine for a period of 10 days starting from 13th May. Home and close contacts of the febrile staff and patients will also be put under Home Quarantine.

In addition, IMH will implement the following preventive measures with immediate effect to limit any exposure of the community:

- No admission of new patients
- No discharge of current inpatients
- No movements of patients and staff across wards. No referral of inpatients to other hospitals. Urgent medical problems will be managed by TTSH
- Closure of its outpatient services
- Closure of its Accident and Emergency services

Existing inpatients who are currently being treated in IMH will continue to be managed there. All IMH staff will also be closely monitored through thrice daily temperature measurements. As an added precautionary measure, all IMH staff will be housed in designated stand-alone housing flats for 10 days. Although the staff are currently well, the IMH senior management and staff have decided on this measure to facilitate close monitoring to ensure their well being as well as to minimise contact with the community and their loved ones.

14 May 2003:

There are currently 27 patients and 10 staff warded in TTSH for observation of fever. The patients are from Wards 64, 65, 35 and 50B.

Follow-up appointments for outpatients

Outpatients who may miss their follow-up appointments as a result of the closure of the outpatients? clinic at IMH will be contacted progressively by IMH staff. From 16 May 2003, Friday, these patients will be seen at Alexandra Psychiatric Outpatient Clinic along Viking Road. This clinic will open from 8am to 8pm and will be manned by a team of nurses and a psychiatrist who have not been in IMH?s premises since 23 April 2003.

Hotel Accommodation for IMH Staff

124 IMH staff members moved into holding accommodation from Housing Board's flats in Woodlands last night but all IMH staff will be provided with accommodation in hotels from today. IMH senior management will like to ensure that their healthcare workers? well being and needs are catered for as the welfare and morale of our healthcare workers is especially important during this period, All IMH staff members who are being relocated are currently well and not infectious. They are at low risk for contracting SARS and will still continue to care for patients under their charge at IMH.

All IMH staff will have their temperature monitored thrice daily. During their stay at the hotel, they will stay in their rooms and will not have any visitors or use the hotel?s facilities.

Comment:

Mr Lim said the hospital had followed the strict gown-glove-mask requirements at its emergency department and the other key areas, but not in the chronic-illness wards 'because they see these as long-staying patients with very little movements'.

There was some consolation, though, because the no-visitor rule which started on April 29 means that apart from patients and staff, the community at large was not likely to be affected.

中華心理衛生協會、中國輔導學會、台灣心靈健康資訊協會、心靈園地與台灣心理諮商資訊網共同建置