UMMC’s Medicine Department Mulls ‘Zero HO Protocol’, With Indefinite Critical Houseman Shortage

A dire houseman shortage is forcing UMMC’s Medicine Department to mull a Zero HO Protocol: operating without HOs. The department is cutting certain services and collecting reported cases of suboptimal care or “near misses” resulting from manpower shortage.

KUALA LUMPUR, Jan 15 – A dire shortage of house officers (HOs) has forced the Department of Medicine at Universiti Malaya Medical Centre (UMMC) to consider adopting a “Zero HO Protocol”.

The “Zero HO Protocol”, termed by UMMC’s Department of Medicine (DOM) acting head, urges staff at the largest department of the public university hospital in the Klang Valley to operate “under the assumption that we no longer have the services of house officers”.

“Personally, I fail to understand how it is that a tertiary, quaternary centre like UMMC serving a densely populated area like KL and PJ can be denied the services of HOs. The irony that we are the most prolific producer of medical graduates is not lost on us,” the DOM acting head said in a WhatsApp message to department staff last December 20, as sighted by CodeBlue.

“To address this dire situation, may I propose what I term is the Zero HO Protocol until the situation becomes normal, if ever that is possible.”

In a separate letter drafted by the DOM acting head and a couple of other doctors that was emailed to the department’s staff last January 2, requesting feedback, it was stated that UMMC’s medicine department is undergoing a “dire shortage” of both trainee doctors (HOs) and medical officers (MOs).

“The situation is critical with no end in sight,” stated the DOM’s January 2 letter, as sighted by CodeBlue.

“With the current house officer shortages, the existing manpower (available house officers, medical officers) are stretched too thin to run a service at full capacity, with high likelihood of burnout of the current staff. Additionally, specialists and consultants who have to help out with the routine clinical duties will also face disruptions in carrying out their core duties in leading the clinical team, teaching, administration and research.

“If the situation persists, the entire department will not be able to function optimally,” the DOM’s January 2 letter read. “We are now in the process of eliminating certain services.”

The letter did not specify what services were being cut from the department.

The medicine department is recognised as the busiest among UMMC’s inpatient, outpatient and procedural-based departments, accommodating over 300 inpatients concurrently and contributing to 20 per cent of the hospital’s inpatient services.

DOM’s clinics serve approximately 1,000 patients daily. With the ongoing resurgence of Covid cases, the medicine department foresees another surge in admissions, placing an additional burden on its operations.

‘Severe’ Doctors’ Shortage Risks Patient Safety, ‘Near Misses’ Reported

The DOM’s January 2 letter openly admitted the risk to patient safety as a result of the “severe” manpower shortage in UMMC that generally takes in highly complex cases, requiring a fully functional team of clinicians from seniors to juniors to ensure quality care.

The public teaching hospital, the letter noted, often receives cases from reputable private health care institutions that are complex as they are referred to UMMC as a last resort. Accompanying relatives frequently express anger and frustration.

“It is to be expected that a lower doctor-to-patient ratio will result in compromise to quality of care and patient safety. This is especially true during out-of-office hours,” said the DOM’s three-page letter.

“Conventionally, house officers are expected to be the first-line in attending any issues that arise among patients, as well as carry out phlebotomy duties, as medical officers have a higher number of wards to cover and are expected to attend to cases of higher urgency and medical emergencies.

“However, with the miniscule numbers of HOs during out-of-office hours (sometimes practically none), medical officers, who may be covering up to five to six wards at one go, have to shoulder the burden of addressing all issues, minor or major, including mundane duties like phlebotomy. This will take away their time or availability to properly assess patients during medical emergencies.

“We are currently collecting reported instances of suboptimal care/ near-misses/ morbidities that have occurred as a result (directly or indirectly) of the severe manpower shortage.”

The DOM’s January 2 letter did not specify what “near misses” have been reported so far that resulted from the dire shortage of doctors.

“We fear the day may come, sooner rather than later, that the reputation of UM as a Centre of Excellence may not be upheld if we cannot ensure even the most basic issue of patient safety.”

The DOM’s letter proposed that only ill, passed-over, and patients with high National Early Warning Score (NEWS) be reviewed during weekend rounds. NEWS is a tool developed by England’s Royal College of Physicians to improve the detection of and response to clinical deterioration in patients with acute illness.

“Our MOs will not review and manage all patients, which involve taking blood, setting up intravenous lines, paperwork, and filling up the cardex. It is not humanly possible to do everything at once.”

Hire Phlebotomists, Let Medical Graduates Do Phlebotomy And Cannulation

The DOM’s January 2 letter outlined a set of countermeasures aimed at managing the heightened workload in the department to maintain lean services. This involves engaging senior clinicians to prevent unnecessary investigations or procedures, deferring or avoiding bio-imaging requests for CT (computed tomography) scans and MRIs (magnetic resonance imaging) outside of office hours, and streamlining clinical procedures.

However, given the high complexity of patients, there is a constraint on how much the Department of Medicine can reduce these essential clinical procedures.

“We, therefore, appeal to the management to take swift measures to address this dire situation. These [measures] include engaging the nursing workforce to identify phlebotomy-trained staff to assist in routine blood taking or cannula insertion, appealing to the management to consider hiring phlebotomists, as well as appealing to the Ministry of Health (MOH) for allocations of house officers,” read the DOM’s January 2 letter.

Phlebotomists are medical professionals trained to draw blood. IV cannulas, which are a thin tube inserted into a vein, are used for blood draws, administering medication, or providing fluids.

“University Malaya’s medical degree is acknowledged to be the best in the country. Yet, our graduates could not be hired to help with phlebotomy and cannulation. We propose that we give them an opportunity to do PRINT 2.0 but this time, they are paid a stipend for their effort.

“We should give them the privilege to do phlebotomy and cannulation, as well as basic clerking and filling up the paperwork. This will prepare them for life as house officers as well as keeping their skills sharp while waiting for their posting from the Ministry of Health,” the DOM’s January 2 letter said.

PRINT 2.0 are pre-housemanship students.

Matter Of Time Before Rakyat Begin To See That ‘The Health Care System Is Failing’

The DOM’s January 2 letter noted that the long wait for a “decent post” is one of the factors driving Malaysian medical graduates to countries like Singapore.

The letter also pointed out that Malaysian medical graduates are underpaid compared to their Singaporean counterparts, even after adjusting for income tax and rent.

“Young graduates are struggling to keep up with the exorbitant cost of living. It is shameful when elder authorities insinuate that the graduates are all driven by monetary gain,” said the DOM.

“What Singapore offers is a shorter lag between graduation, starting work and specialist training. This appeals to many of our graduates who come from poor families and cannot wait for seven idle months, and we must take into consideration that the Malaysian government only pays them after three months of working.

“Singapore also has a clear and transparent pathway for specialisation and permanent posting.”

The DOM’s January 2 letter criticised the Malaysian government for not coming up with “any clear guidelines”, despite this issue having been highlighted for the past decade.

“The Ministry of Health can confirm if the number of applications for HO and MO posts are dwindling. We expect this to be the case given the current situation. We urge for a more robust and faster processing of applications, and increasing the number of intakes to six per year, that is consistently sustainable and reflects the increasing number of Malaysian medical graduates per year,” stated the DOM’s letter.

“In closing, we would like to highlight the long waiting hours experienced by Malaysian patients in public health care institutions, in both inpatient and outpatient settings, including emergency departments. It is only a matter of time before the rakyat are affected and begin to see that the health care system is failing.

“The shortage of HOs and MOs is an urgent problem and we need solutions and actions now.”

What Is Zero HO Protocol?

The Zero HO Protocol proposed at the medicine department in UMMC involves smaller units forgoing house officer services, prioritising house officers in high workload units like respiratory medicine and infectious diseases, discontinuing “indiscriminate” test requests, and exercising “mindfulness” in admitting patients.

The protocol also notes that at-risk patients should be in the intensive care unit (ICU), with only stable patients in the medicine department’s wards. Any tests ordered by medical officers should be performed by the doctor themselves.

“If you feel your patient needs an IV cannula, this will be a good time to practise your skills. Or get someone in your team to do it during office hours. [If] the patient needs a CT scan or an MRI, there are ample laptops to make the request, and the radiologist is just a phone call away,” the acting DOM head wrote in his December 20 WhatsApp message to staff.

“All bloods are to be taken in the morning and reviewed before noon for action. Again, [if] you want a renal profile three times daily, please ensure that you perform the procedure and review the results yourself. Or better still, use your clinical judgement. If there is a need for bloods the next day, request it today so the MO can take the bloods in the morning the next day.”

The acting DOM head also said whatever tasks given to HOs must now be shared among MOs, lecturers, and consultants.

“Let’s put an end to indiscriminate requests for tests that are being made just because we assume we have the convenience that someone else is always available to carry out our orders.”

In his message last month, the acting DOM head further urged staff to “be mindful” of admitting patients to the ward. “If you admit the patient, then the management plan falls upon you.”

The acting DOM head’s December 20 WhatsApp message to staff acknowledged the possibility that the lack of housemen could be one of the main reasons for “indiscriminate” leave applications by medical officers.

“If the workload is beyond what MOs would experience in KKM (Ministry of Health) hospitals, there will be fatigue and resentment.”

CodeBlue understands that despite the acting DOM head’s call to implement the Zero HO Protocol, it is not being fully enforced.

“Not exactly [being implemented]. Because bloods are still ordered rampantly, and MOs are expected to take blood, review patients, give a plan, request imaging, update family, and go down to the clinic on time. [We] don’t really know how to multitask that way,” a source at the university hospital told CodeBlue.

Units in the DOM like geriatrics are also making daily requests for blood. “It needs to be highlighted that in geriatrics, sometimes the order is to take blood a few times in the same patient – already their lines are so small and fragile.”

CodeBlue understands that a final version of the January 2 draft letter by the acting DOM head and some doctors – upon gathering feedback from department members – is intended to be sent to UMMC director Dr Nazirah Hasnan. However, it is unclear if the letter has been sent out.

UMMC’s top management has yet to provide a response to CodeBlue after a request for comments on the situation.

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