Today’s question comes from a paramedic. The question is generic and given pending national registration their jurisdiction does not matter. The question is:
In light of registration quite a few paramedics are discussing the potential opportunities for paramedics to clinically practice in areas that have not traditionally employed paramedics; for example in hospitals or doctors’ offices. However, it seems that one of the possible impediments to this is the fact that the ability to administer scheduled medications seems to be tightly controlled. What impediments, if any, would a paramedic face if (for example) there was a will to employ one in an ER in order to allow them to work clinically to the same scope of practice as they would with a state ambulance service. Would they be able to administer scheduled medications to the patients in the ER? Would they be able to administer any medications? Would this require the approval of the State Chief Health Officer (or equivalent). Could a medical doctor ‘delegate’ the authority for the paramedic to administer medications – in effect, to grant the paramedic an ‘authority to practice’ similar to how an ambulance service does? What legal requirements would have to be satisfied for a paramedic to administer medications to patients in a place of employment other than an ambulance service?
The answer to this question is ‘it depends’ but let me explain that in more detail.
First, in my view, paramedic registration is going to change the nature of paramedic practice, but it won’t do that overnight. Once paramedics are registered it will be possible for health departments to make rules that relate to ‘paramedics’, for example they will be able to make rules to the effect that ‘a paramedic may carry the following drugs’ (or some such). That they will be able to do that doesn’t mean they will and it certainly doesn’t mean they will when registration commences. Deciding what authority to give to paramedics will depend on evidence and arguments and timing submissions eg when poisons legislation comes up for review.
Other things that I think will come with registration and was in fact part of the argument for registration is the scope for paramedics to move their practice from traditional jurisdictional ambulance services. So work in hospitals and GP surgeries will open up and I would anticipate that entrepreneurial paramedics will find other business models, including private emergency ambulance services, where they can earn a living. Again these things won’t happen overnight, but paramedic registration will mean that the term ‘paramedic’ means something and that in turn will open doors for new sorts of practice.
Currently it is not administering scheduled medicines that is regulated, it’s possession of those drugs. Let me use NSW as an example. A person who is employed by the Ambulance Service of NSW as an ambulance officer is entitled to carry scheduled drugs in accordance with an approval from Director-General (Poisons and Therapeutic Goods Regulation 2008 (NSW) r 101 and Appendix C, cl 7). That is not a delegation from a doctor. Doctors (except in WA) do not have some general authority to allow other people to carry drugs – see Doctors delegating authority to carry drugs (August 20, 2014). The reason an office holder like the Director General of Health or perhaps a medical director of a private ambulance service can identify who can carry scheduled drugs is because the relevant poisons legislation says they can, it is not a right or authority that comes with registration as a medical practitioner.
But the authority under the relevant legislation is a right to possess and supply the drugs. For paramedics that means they can carry the drugs in their drug box and decide, without reference to a medical practitioner, whether the patient’s condition requires the drugs to be administered. But a person may administer drugs to a person for whom the drugs have been prescribed (Poisons and Therapeutic Goods Regulation 2008 (NSW) rr 58 and 59). That means a paramedic employed at a hospital or a GP could administer drugs if they have been prescribed for the patient by the medical practitioner. Where the drugs are required to kept under lock and key the paramedic, without express authority, could not hold the key to the drug cabinet and therefore be ‘in possession’ of the drugs that have not been prescribed.
But that’s the position in New South Wales. In Western Australia the Medicines and Poisons Act 2014 (WA) s 25 says:
A health professional acting in the lawful practice of his or her profession is authorised to administer, possess, prescribe, supply or use a medicine if —
(a) the health professional is a member of a class of health professional prescribed by the regulations; and
(b) the medicine is prescribed by the regulations as one that may be administered, possessed, prescribed, supplied or used by a member of that class of health professional; and
(c) the administration, possession, prescription, supply or use of the medicine is in accordance with the regulations.
Paramedics are already authorised health professionals and may carry schedule 2, 3, 4 and 8 medications. They may administer schedule 4 and 8 medications on the prescription of a medical practitioner or in accordance with a structured administration and supply arrangement (an SASA) (Medicines and Poisons Regulations 2016 (WA) rr 15, 61 and 62). Pending registration, a paramedic is ‘a person employed by the holder of a health service permit to provide ambulance or paramedic services’ (r 37). Assuming that the definition of paramedic is amended with registration one can infer that in WA a paramedic will be able to carry and supply drugs in accordance with a relevant SASA but whether that would allow them to be in charge of the drug cabinet or make the decision, without referral to a medical practitioner, to administer drugs would depend on the terms of the SASA.
Further s 27 of the WA Act says:
An employee or agent of a health professional acting within the scope of the employee’s or agent ’s actual or apparent authority, may do anything that is authorised by the professional authority of the health professional, other than to prescribe a medicine.
If a paramedic is employed by a medical practitioner then the paramedic could administer a drug that has been prescribed for the patient by the employing medical practitioner.
The authority of paramedics to possess and make independent decisions to administer scheduled drugs is found in the state and territories poisons legislation. The terms of the legislation varies from jurisdiction to jurisdiction.
Registration of paramedics will not automatically see paramedics authorised to carry and administer drugs on their own initiative but it will be a start. It will be easier for health departments to grant that authority if they see the need and identify that the profession is sufficiently mature and well-regulated to protect patient safety. Registration will not bring that but it will be a critical first step. Health Departments will know that registered paramedics have had their qualifications assessed and can be disciplined if they abuse their position of trust so will be able to make a rule that applies to ‘paramedics’.
Identifying need will be essential and if paramedics are moving out of the traditional ambulance services and can bring pressure to make those changes, supported by those that may want to employ them, that will no doubt be considered by health departments in due course.
Pending that paramedics can help a patient by administering medication that has been prescribed for that patient, just as anyone can.
I would like to know what the situation is with maintaining a Drug Register. Typically policy has been that DDs must be checked by Two HCPs one of which is a Registered Nurse or Registered Midwife. This policy enables an RN to check DDs with an EN but two ENs would not be able to check the DDs together. An RN may also check the Drugs with a Pharmacist and indeed this will happen when Drugs are added or removed from stock. I have also checked drugs with Registered Medical Practitioners from time to time. My questions are: How will Registered Paramedics (RPs?) fit into this picture? What would be the legal situation and/or advisable practice for managing DDs in a community or pre-hospital environment involving a mix of RNs and RPs ?
DD is ‘dangerous drugs’. The answer to this question is ‘it remains to be seen’. If I look at the Poisons and Therapeutic Goods Regulation 2008 (NSW) r 117 it says that an entry in a hospital drug register that relates to the supply of a schedule 8 drug to a patient must “be dated and signed by the person by whom it is made and countersigned … (i) by the person who supervised or directed its supply or administration, or (ii) by a person who witnessed its supply or administration.” That doesn’t say anything about the person’s qualifications (that will be found elsewhere for relevant authorities to possess or supply drugs). In Western Australia the Women and Newborn Health Service, King Edward Memorial Hospital, Clinical Guidelines Pharmacy and Medications (August 2014) says (at ):
A paramedic is not in that list but may be included should the hospital which to do so. How hospitals and health authorities change policies to reflect paramedic registration will remain to be seen. Equally how an agency manages scheduled drugs in a community or pre-hospital setting remains to be seen. As at today there is no change from practices on 31 November 2018. But that may change. See Administering drugs when paramedics are registered (October 3, 2018) and Administering drugs when paramedics are registered – Queensland(October 17, 2018)