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Doctor's Responsibility to the Implementation of 24 Hours Emergency Unit Service in Non Primary Health Care Center of Land Bumbu District
Laurensius Lungan
1*, Ontran Sumantri Riyanto
2, David Maharya Ardyantara
3, Arman Harahap
41*Universitas 17 Agustus 1945 Semarang, Indonesia. E-mail: [email protected]
2Sekolah Tinggi Ilmu Kesehatan Bethesda Yakkum Yogyakarta, Indonesia.
3Universitas 17 Agustus 1945 Semarang, Indonesia.
4Universitas Labuhanbatu Sumatera Utara, Indonesia.
ABSTRACT
Regent Decree of Tanah Bumbu Number 188.46/265/Dinkes/2006 about 24 hours emergency unit service at non primary health care center in Tanah Bumbu District, cause problems at impelementation. Limited number of doctors, and not yet fulfilled the standard of rooms, medical devices, and medicines in 24 hours emergency unit service at non primary health care center, made the author interesting to study about doctor’s responsibility of health service based on the Regent Decree.
The research is sociological juridical and the data collection technique used was interviewing several informants at the public health office, primary health center, legal section of the regional government, Indonesian Medical Association, and experts of state administrative law, as well as library studies, and related documents. Based on the results of the study it can be concluded that the regent decree can be cancelled (voidable), cause legally formal the signing of head of the public health office exceed the authority limit, as well as substance not yet fulfilled the legal fundament. Then at implementation, the doctors responsibility not yet fulfilled, both ethically and legally, in the afternoon and evening, after government employee’s daily working hours, where there is forgiveness reason, at risk for fatigue and negligence, outcome the number of doctors is limited. On the other hand, the doctors responsibility not yet fulfilled the standard of proffesion, standard operating procedures, and service standart, because not yet fulfilled of rooms, medical devices, and drugs criterion in 24 hours emergency unit service at non primary health care center.
KEYWORDS
Regent Decree, Responsibility, Forgiveness Reason.
Introduction
Health as a fundamental social right, in the 25th article of the United Nation Declaration of Human Right 1948, appears in international programs through the World Health Organization (WHO). (WHO, 2020; Supriyatin, 2018).
Through the Constitution of the Republic of Indonesia Year 1945, Indonesia has also stipulated that health is the right of every citizen. Everyone has the right to protect his health, and the state is responsible for regulating the fulfilment of the right to a healthy life for its citizens. (Kementrian Kesehatan, 2016). The government in the development of health aims to realize an optimal degree of public health, by organizing health efforts that are equitable and affordable, in a harmonious and balanced manner, involving the public's participation, including the private sector. (Hanafiah & Amir, 2016). In this case, health development is organized based on humanity, balance, benefits, protection, respect for rights and obligations, justice, gender, and non-discriminatory, and religious norms, by Article 2 of the Law of the Republic of Indonesia Number 36 the Year 2009 on Health.
Emergency Unit Services (ER) is the spearhead of health services in hospitals and health centres care, with a service time of 24 hours every day. The goal is to provide first aid to patients who come and avoid various risks. Therefore, the existence of doctors for direct service is needed for 24 hours every day. Patients classified as an emergency will be immediately carried out actions to save the patient's life. Meanwhile, for patients who are not emergency, health services will be carried out according to their needs(Dr. D. Mulyadi et al., 2013). To improve emergency services at the central level of public health (Health center) Tanah Bumbu district, the Health Office, through the Regent of Tanah Bumbu, issued a regulation to require every non-care health centre to carry out emergency unit services 24 hours. This certainly gets appreciation by the community. But in reality has not met the expectations during its implementation, where patient services are often only carried out by nurses guarding with building facilities or rooms and medicines and medical devices roughly. There are still various obstacles to get health services from doctors protecting the Emergency Unit 24 hours in non-treatment health centres.
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The main obstacle that may occur is the availability of human resources in performing health services in non-care health centres. Especially in doctors' availability. (Nasrul, 2014; CHUANG & Liao, 2010; Wei, 2006; Schuler, 1992). The number of doctors in each non-treatment health centre is at least 1 to 2 doctors, where the doctor carries out health services to the population in one sub-district in the division of the working area of the Health center where the duty. To carry out excellent service, it takes a sufficient number of doctors in supporting various programs in non-treatment health centres, including 24-hour Emergency Unit services. (Nur et al., 2019).
To carry out services faster, it requires a home office facility or a 24-hour doctor's room in a non-treatment health centre. This is necessary so that doctors do not need to live outside the Health center and reduce the risk of the doctor's journey from home to the health centre in carrying out emergency efforts 24 hours. (N. Mulyadi & Hamel, 2018). Operational funding of communication equipment also needs to be considered in supporting the handling of 24-hour Emergency Unit patients in non-care health centres. Doctors who perform emergency services also need to be facilitated to attend life support training to provide more quick and appropriate emergency patients treatment (Alamsyah et al., 2020; Nyandra et al., 2018).
Another obstacle that is no less important in the 24-hour Emergency Unit service in non-treatment health centres is in the provision of various supporting facilities in the management of patients. (Hendianti et al., 2012), namely medicines, tools, and consumables for emergency conditions, as well as triage rooms and temporary inpatient rooms for patient observation. The tools needed to support both diagnosis and emergency measures are generally incomplete as required. Drugs and consumables are also typically not equipped, according to the management of emergency patients. The limitations of the Health center building facilities cause the need for temporary inpatient rooms and facilities, patient observation before being referred to the hospital, and other obstacles for doctors.
(Pertiwi et al., 2017; Febrian et al., 2020). Based on the description of the problem above, the author is interested in finding answers. How is the practice of implementation in health services by doctors in the Emergency Unit 24 hours Health center Non-Care Tanah Bumbu district? What is doctors' responsibility in the performance of the Decree of the Regent of Tanah Bumbu No. 188.46/265/DINKES/2016 on 24-hour Emergency Unit Services at the Non- Maintenance Health Center of Tanah Bumbu Regency, both ethically and legally?
Methods
This research uses a sociological juridical approach method, which is a legal approach that applies to society. The specifications of this research are explanative. The types of data used in this study are primary data and secondary data. Primary data is data obtained from interviews with respondents and resource persons. In contrast, secondary information is data obtained from the study of various literature or library materials related to problems or research materials. This study used open interview data collection techniques, where in question and answer, respondents were given full freedom to answer. The sample is selected from the population according to the researcher's wishes with consideration or purposive sampling. Data Analysis Method in this research uses qualitative data analysis.
(Elsiddig Ahmed, 2020; Cassell et al., 2017; Flick, 2013; Willig & Rogers, 2017).
Result and Discussion
The research was conducted at 4 Health center in Tanah Bumbu District, namely Batu licin Health Center, Darul Azhar Health Center, Karang Bintang Health Center, and Tanjung Island Health Center. The interview was also conducted directly in the legal section of the Local Government of Tanah Bumbu District, the Health Office of Tanah Bumbu District, and on four Non- Maintenance Health Centers in Tanah Bumbu District.
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Fig. 1. Health center Non Care Karang Bintang and ER Health center Non Care Karang Bintang, Health Office Tanah Bumbu District, South Kalimantan Province
Fig. 2. Health center Non Care Tanjung Island and ER Health center Non Care Tanjung Island, Health Office Tanah Bumbu District, South Kalimantan Province.
In the Republic of Indonesia's administration, the government has the authority in the establishment of legislation that is a guideline in regulating various things in society. This is called the method of law, based on its content, the
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method of law is divided into legal methods containing commandments, prohibitions, and allows. While by its nature, the method of law is divided into imperative and facultative legal methods. The legal method of which the order's contents or prohibition is critical is binding or coercive, while the facultative content is a complementary, subsidiary, or dispositive. (Mertokusumo, 2007; Suwarba, 2021; Velázquez et al., 2021). Decree of the Regent of Tanah Bumbu No. 188.46/265/DINKES/2016 concerning 24-hour Emergency Unit Services in The Non- Maintenance Health Center of Tanah Bumbu District is a legal method containing orders and is imperative. In its implementation, the Decree of the Regent of Tanah Bumbu is an order to all non-maintenance Health Centers in Tanah Bumbu District to carry out 24-hour Emergency Unit services.
In accordance with Article 97 of the Law of the Republic of Indonesia Number 12 the Year 2011 concerning the Establishment of Legislation, the Decree of the Regent of Tanah Bumbu No. 188.46/265/DINKES/2016 concerning 24-hour Emergency Unit Services in The Non-Maintenance Health Center of Tanah Bumbu District is included in the type and hierarchy of applicable Laws and Regulations, where the drafting techniques are the same or apply mutatis mutandis of the type and hierarchy of legislation. In the system of Legislation of the Republic of Indonesia also adheres to a hierarchy system. In regulating the same, the legislation of a lower level should not be contrary to higher. This legal principle is called adagio lex superior derogat legi inferiori. Higher legislation will take precedence over more subordinate legislation, in the event of a conflict in the regulatory material to regulate the same. (Purba, 2007).
While in its implementation where health services by doctors based on Professional Standards, Standards of Operational Procedures and Service Standards in emergency services in the ER 24 Non-Care Health Centers, in accordance with Article 51 letter law of the Republic of Indonesia Number 29 the year 2004 concerning Medical Practice, Article 21 paragraph (2) regulation of the Minister of Health of the Republic of Indonesia Number 2052/Menkes/Per/X/2011 concerning License of Practice and Implementation of Medical Practice, and Article 37 paragraph (2) regulation of the Minister of Health of the Republic of Indonesia Number 75 the Year 2014 concerning Public Health Center, cannot be fulfilled. This research, based on the results of interviews with the Health Office and observations in non-maintenance health centres, minimum equipment standards in the Emergency Unit 24 hours non- care Health center have not been met, in accordance with the minimum equipment standards in the Attachment to the Regulation of the Minister of Health of the Republic of Indonesia Number 75 the Year 2014 on Public Health Centers, which potentially health services provided by doctors to be not optimal.
The Local Government Law was drafted to implement Article 18 of the Constitution of the Republic of Indonesia Year 1945 in state regulation, in which the Indonesian system of government is divided into central and local governments. This is mentioned in Law No. 23 of 2014 on Local Government, where the central government gives local governments autonomy to manage and manage their regions.
The exercise of authority can only be carried out in a manner determined by law. The authority to make decisions can only be obtained in two ways: attribution or Delegation. Attribution is the authority granted by the Constitution or Law to an office. At the same time, the Delegation is the transfer of authority from one governing body to another.
So in the Delegation, there is a replacement of the owner of authority from the delegator to the delegate's recipient.
Based on the Decree of the Regent of Tanah Bumbu No. 188.46/265/DINKES/2016 concerning 24-hour Emergency Unit Services in The Non-Maintenance Health Center of Tanah Bumbu Regency, the Regional Government of Tanah Bumbu District, has carried out Mandatory Government Affairs related to Basic Services as referred to in Article 11 paragraph (2) letter b covering Health, which is carried out by the Health Office of Tanah Bumbu Regency.
Authority in the establishment of the Regent Decree is Attribution. The Regent's authority by attribution is obtained from the Constitution of the Republic of Indonesia Year 1945 Article 34 paragraph 3, Article 12 paragraph (1) of Law Number 23 the Year 2014 on Local Government, and Article 19 of Law No. 36 of 2009 on Health.
In the case of delegation of authority(Mueller & Vogelsmeier, 2013), regulated in the delegation of authority for the signing of the Decree of the Regional Head, mentioned in Article 115 paragraph (3) of the Regulation of the Minister of Home Affairs of the Republic of Indonesia Number 80 of 2015 concerning the Establishment of Regional Legal Products, that the Signing of the Regional Head Decree as referred to in paragraph (2) can be delegated to the deputy regional head, regional secretary, or regional device leader.
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Practice health services by doctors in the Emergency Unit 24 hours Health center non Care Tanah Bumbu District
ER services are important services to be carried out in every Health center if the Health center in question have sufficient resources in providing ER services to the community. This is mentioned in the book Standard Health center where for Health center who do not have ER services. (Ali et al., 2018), it is important to improve its resources and provide ER services according to the needs of the community. In addition, it is also mentioned in the JKN Socialization Handbook, that emergency services are a mandatory service, which must be available in various health facilities including in the Health Center, to provide initial treatment for patients in emergency conditions, to be further referred for further treatment in the hospital (Chabibah & Chalidyanto, 2014; Widana 2020; Wijaya et al., 2020). Based on the Emergency Services Guidelines compiled by the Ministry of Health of the Republic of Indonesia in 1995, emergency services provide quick and appropriate action to patients in the Emergency Department to prevent unnecessary disability and minimize the death rate. In an effort to improve emergency services, efforts are needed to improve various resources required, so that initial assistance in emergency patients can be in accordance with doctor's professional standards, standards of operational procedures, and minimum service standards in Health center. (Kemenkes RI, 2016).
Table 1. Number of Cases in 24-Hour ER in Batulicin Health center, Darul Azhar Health center, Karang Bintang Health center, and Tanjung Island Health center, in June 2016-May 2017 and June 2017-May 2018.
Data source: 24-Hour ER Patient Register Book at Batulicin Health center, Darul Azhar Health center, Karang Bintang Health center, and Tanjung Island Health center, Tanah Bumbu District, South Kalimantan Province.
Health services by doctors in the Emergency Unit 24 hours Non-Care Health Center is only carried out at the working hours of daily employees, namely at eight in the morning until three in the afternoon, on Mondays to Thursdays, then until eleven noon on Fridays, and until half-past three in the afternoon on Saturdays. This is due to the limited number of doctors in every non-treatment Health center, where from the observations of researchers, the number of doctors who were active during this study was as many as two doctors in the batulicin health centre, three doctors in Darul Azhar Health Center, two doctors in Karang Bintang Health Center, and two doctors in Tanjung Island Health Center. The difference in the number of existing doctors is calculated based on the definitive decree of staffing, namely in the Batulicin Health Center which is written four doctors, currently, only active two doctors, caused by two other doctors, are studying specialist doctors. Then in The Tanjung Island Health Center, from 3 doctors, currently only functional two doctors, because one doctor the other, is being assigned through a memorandum of staffing, to the Health center Lasung treatment, because in Health center Lasung there is currently only one active doctor. In contrast, the Health center Lasung treatment is a health centre that carries out inpatient services. Another cause is the absence of a duty of care to the doctor.
The next health service after the Health center doctor came home, named after three o'clock in the afternoon until eight in the morning the next day, served by nurses and midwives guarding the non-care Health center, based on the
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Decree of the Head of non-care Health center about the Delegation of Authority from the doctor to nurses and midwives guard made to meet the accreditation requirements. Doctors are only consulted via a personal mobile phone from nurses and look after midwives, if necessary. The doctor's house's distance starts from a distance of two kilometres to twenty-five kilometres from the non-treatment Health center on duty. There is no obligation for doctors to take care in the afternoon and evening until the next morning, after the employee's daily work hours.
The standard of personnel of doctors who serve in the Emergency Unit must have a certificate of Advanced Trauma Life Support (ATLS), Advanced Cardiac Life Support (ACLS), and Emergency Management (PPGD). The doctor's schedule on duty is arranged into three-guard plans every day, namely morning, noon and night, where each old program is served 8 hours. This is in accordance with the Guidelines for Emergency Services compiled by the Ministry of Health of the Republic of Indonesia year 1995. From 4 non-treatment health centres, it was obtained that not all Health center doctors have a certificate of emergency training. This is because emergency training is still followed by doctors with personal financing, as well as the absence of an obligation to have an emergency certificate and no responsibility as a doctor guarding the Emergency Unit 24 hours Non-Care Health Center, outside the working hours of the morning service in the morning, by the Health Office of Tanah Bumbu Regency. In addition, there is no obligation for every doctor to attend emergency training.
The standard of Emergency Unit facilities for doctors to take care of is the presence of a doctor's room. In addition, emergency patient services require triage rooms, non-surgical rooms, trauma rooms, and PONED emergency rooms (Basic Neonatal Emergency Obstetrics Services). Standard equipment available in the Emergency Department, medicine, and ambulance must also be life-saving. Of the four non-care health centres, there is no doctor's room and triage room in carrying out health services in the Emergency Unit 24 hours Non-Care Health Center. There is only one room for Emergency Department services, in which there are two beds used for examination, action, and observation of patients. Facilities room, medical devices, and completeness of medicine life-saving Emergency Unit 24 hours Non-Care Health Center is also still rough, not in accordance with the Regulation of the Minister of Health No. 75 of 2014 on Health center. (KEMENTRIAN RI, 2014).
The responsibility of doctors in the implementation of the Decree of the Regent of Tanah Bumbu No.
188.46/265/DINKES/2016 concerning the service of the 24-hour Emergency Unit at the non-care Health Center in Tanah Bumbu district.
In the implementation of health services in the Emergency Unit 24 hours Health center non-treatment, there are several articles in the Indonesian Medical Code of Ethics Year 2012 related to doctor ethics responsibility. (Putri et al., 2015). In the General Obligation section of Article 1 (Doctor's Oath), it is stated that every doctor must uphold, live, and practice the oath and or doctor's appointment. Where in the 7th point of the Indonesian Doctor's Oath, it is stated that "I will always put the health of patients first, taking into account the interests of the community."
Furthermore, in Article 2 of the Good Standards of Medical Services, it is stated that a doctor must always make professional decisions independently, and maintain professional conduct in the highest measure. And in the Section of Doctor's Obligation to Patients Pasa 17, it is mentioned that every doctor is obliged to perform emergency assistance as a form of human duty unless he believes someone else is willing and able to provide it. A doctor is obliged to assess whether or not essential life support is needed for each patient during an emergency call he/she receives in the surrounding area.
In the Doctor's Obligation to Yourself Article 20 (Maintaining Health), it is stated that every doctor must always maintain his health, in order to work correctly. Furthermore, in Article 21 (Development of Medical Science and Technology), it is stated that every doctor must always follow the development of medical science and technology and technology related to health.
As implementers of health services in health facilities, doctors have a legal responsibility to carry out emergency health services. In the case of an emergency, health care facilities, both government, and private are obliged to provide health services for patient lifesaving and disability prevention first. It is mentioned in Article 32 paragraph (1) of the Law of the Republic of Indonesia Number 36 the year 2009 concerning Health. Furthermore, article 32 paragraph (2) stated that healthcare facilities, both government and private, are prohibited from rejecting patients or asking for a down payment in an emergency. (Presiden RI, 2009).
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Doctors can give delegation of authority to nurses in non-care health centres. This is stipulated in Article 23 of the Regulation of the Minister of Health of the Republic of Indonesia Number 2052/Menkes/Per/X/2011 concerning License of Practice and Implementation of Medical Practice, where in paragraph (1) it is stated that the doctor can give the granting of medical action to nurses or midwives, in writing in carrying out medical activities. Then in paragraph (2), it is stated that the medical action bestowed, can only be done in circumstances where there is a need for services that exceed the availability of doctors in the facility. And in paragraph (3), there is a provision for the delegation of actions, namely:
a. The actions bestowed are included in the abilities and skills that have been owned by the recipient of the delegation.
b. The implementation of the delegated action remains under the supervision of the grantor.
c. The grantor remains responsible for the actions bestowed throughout the implementation of the action in accordance with the grant given.
d. The actions bestowed do not include taking clinical decisions as the basis for the implementation of the action.
e. The actions bestowed are not continuous.
Health services in the Emergency Unit 24 hours Non-Care Health Center, can not be carried out in accordance with standards of operational procedures and service standards, as well as equipment standards, not yet in accordance with the Regulation of the Minister of Health No. 75 of 2014 on Health center. (KEMENTRIAN RI, 2014). This is because the room, medical devices, and life-saving medicines are not available according to the required standards.
Legally, doctors can also not fulfil the rights and obligations to carry out services in accordance with professional standards, standards of operational procedures and service standards, in accordance with applicable laws and regulations(Suryadi, 2009). In this case, professional standards, standards of operating procedures and service standards will only be able to be carried out properly, if various necessary facilities can be met, namely room facilities, medical devices, and completeness of life-saving medicine in the Emergency Unit 24 hours Non-Care Health Center, in accordance with the Guidelines for Emergency Services compiled by the Ministry of Health of the Republic of Indonesia Year 1995, and regulation of the Minister of Health of the Republic of Indonesia Number 75 the Year 2014 on Health center. (KEMENTRIAN RI, 2014).
The delegation of authority through the Decree of the Head of Non-Care Health Center on the Delegation of Authority from doctors to nurses and midwives guard, made to meet the accreditation requirements of non-care Health center, can not apply as it should. Where in the delegation of authority in accordance with the Regulation of the Minister of Health of the Republic of Indonesia Number 2052 / Menkes / Per / X / 2011 on The License of Practice and Implementation of Medical Practice, it is mentioned that the delegation of medical action to nurses or midwives, can only be carried out in writing in carrying out medical actions, including in the ability and skills that have been possessed by nurses or midwives, the implementation of the act remains under the supervision of doctors, the action bestowed does not include taking clinical decisions as the basis for the implementation of actions, as well as actions that have not been delegated continuously. So that in accordance with the applicable regulations, the delegation of authority by doctors to nurses and midwives guard only apply once, and needs to be made whenever necessary, where the doctor who delegates authority is also in the non-care health centre.
So that doctors' responsibility, both ethically and legally. (Lovatt, 2010), to provide health services directly in the Emergency Unit 24 hours Health center non-treatment, outside the employee's daily service hours, namely in the afternoon and evening, until the next morning, can not be met. This is due to the reason for forgiving the risk of fatigue factors because the availability of the number of doctors in the Emergency Unit 24 hours Non-Care Health Center is not enough schedule to take care of the required doctor, as well as the inability of doctors in providing services in accordance with professional standards, standards of operational procedures, and service standards in accordance with the Guidelines for Emergency Services and applicable laws and regulations, caused by the standards of room facilities, medical devices, as well as the completeness of life-saving medicines Emergency Unit 24 hours Non-Care Health Center has not been in accordance with the Emergency Services Guidelines compiled by the Ministry of Health of the Republic of Indonesia Year 1995 and attachments to the Regulation of the Minister of Health of the Republic of Indonesia Number 75 the Year 2014 concerning Public Health Centers.
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With these forgiving reasons, the government's responsibility is the main factor in fulfilling the various necessary completeness, both the availability of the number of doctors, as well as buildings, drugs, tools, and various other supporting facilities needed. It is set to have been set out in:
a. The Constitution of the Republic of Indonesia Year 1945 Article 34 paragraph (3), the State is responsible for the provision of health care facilities and proper public health care facilities.
b. Law No. 36 of 2009 on Health Article 19, the Government is responsible for the availability of all forms of quality, safe, efficient, and affordable health efforts.
c. Law of the Republic of Indonesia, Number 23 of 2014 concerning Local Government, Article 12 paragraph (1), Mandatory Government Affairs relating to Basic Services referred to in Article 11 paragraph (2), includes: b. Health.
This research found that in the provision of buildings, medical devices, and emergency medicines, in supporting health services ER 24 hours Non-Care, it is still not complete. So that in the procurement of buildings, drugs and tools needed, always proposed continuously by prioritizing which is more important to be pursued first, in budgeting the Regional Revenue and Expenditure Budget Level I, Regional Revenue and Expenditure Budget Level II, and Special Allocation Fund. If there is no room or building specifically for the ER, while the 24-hour ER service is carried out in the Non-Care Health Center's action room first while waiting for the rehab of the non-maintenance Health center building, or the procurement of a new Health center building. Efforts to add doctors remained discontinued through the acceptance of regional contract doctors. If the doctor is still lacking, then the emergency health service in the 24-hour ER Non-Care Health Center is carried out with a schedule of nurses guard, with the consul doctor by phone if there are emergency patients. (Hogan & Spiegel, 2016).
Based on these results, the Government's Responsibility in the Implementation of Health Services in the Emergency Unit 24 Hours Non-Care Health Center has not been carried out in accordance with the applicable laws and regulations. The government is responsible for fulfilling various supporting facilities and human resources, especially doctors who are needed first, to meet professional standards, standards of operational procedures, and service standards in carrying out health services in the Emergency Unit 24 hours Non-Care Health Center, in accordance with the Code of Medical Ethics year 2012, Law of the Republic of Indonesia Number 29 the Year 2004 concerning Medical Practice, Regulation of the Minister of Health of the Republic of Indonesia Number 2052/Menkes/Per/X/2011 concerning License of Practice and Implementation of Medical Practice, and Regulation of the Minister of Health No. 75 of 2014 concerning Health Centers, before issuing the policy of the Decree of the Regent of Tanah Bumbu No. 188.46/265/DINKES/2016 concerning 24-hour Emergency Unit services in non- maintenance Health Centers tanah Bumbu district.
Conclusion
Authority in the establishment of regent decrees is attribution. In granting the authority of the regent's decree to the Head of the Health Office by delegation, the legal basis used is not in accordance with the legal basis of the state administration, where the Regent Regulation on the Signing of The Regent's Decree, must be based first with the Tanah Bumbu District Regulation, which contains the delegation of authority. And the format in this Regent Decree has not followed the form regulated in the legislation. So it can be concluded that this Regent's Decree can be cancelled, because in its establishment, both substantially and legally formally, is not in accordance with the legal basis of the Establishment of applicable Laws and Regulations, and legally exceeds the authority of the Head of the Health Office in its signing. In the practice of implementing health services in the Emergency Unit 24 hours Non- Care Health Center, Tanah Bumbu Regency, Because of the limited number of doctors and the absence of obligations from the Health Office for doctors to carry out guard duties in the afternoon or evening, doctors provide health services directly only at the daily office hours of employees. While in the afternoon and evening, doctors are only consulted by mobile phone (if necessary), where health services are directly carried out by the care nurse, based on the Decree of the Head of Non-Care Health Center on the Delegation of Doctor Authority to Nurses, which is made to meet accreditation requirements, with the arrangement of nurse care schedule. Patients who come to treatment, more ordinary patients, than emergency patients, where this is in accordance with the original purpose of the wishes of the Regent of Tanah Bumbu so that each health centre can provide 24-hour health services to the community.
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The responsibility of doctors in the implementation of the Decree of the Regent of Tanah Bumbu No.
188.46/265/DINKES/2016 concerning 24-hour Emergency Unit services in non-health centres tanah Bumbu district doctors have not been able to meet the health services directly, after the daily service hours of employees, in the afternoon and evening, both ethically and legally, for reasons of forgiving, namely the limited number of doctors in non-treatment Health center, so there is potential for fatigue or negligence. On the other hand, there is the inability of doctors legally, in providing health services in accordance with Professional Standards, Standards of Operational Procedures, and applicable Service Standards, because of the unfulfilled Standards of Facilities for rooms, equipment and emergency medicines. So that this is the responsibility of the government in fulfilling first, both the number of doctors on duty, as well as the standard of room facilities, equipment, and emergency medicine, in accordance with the Guidelines for Emergency Services of the Ministry of Health of the Republic of Indonesia Year 1995 and Attachment to the Regulation of the Minister of Health of the Republic of Indonesia Number 75 the Year 2014 on Public Health Centers, so that the responsibility of doctors both ethically and legally can be fulfilled.
Acknoledgments
The authors thanked the coconut health office of Tanah Bumbu Regency for supporting this research and the Non- Care Health Center, namely Batulicin Health Center, Darul Azhar Health Center, Karang Bintang Health Center, and Tanjung Island Health Center. And to the sources for invaluable advice.
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