A paramedic from Western Australia (I don’t know what organisation my correspondent works for) is being asked to provide immunisation services.  My correspondent has:

… been asked to complete the “on-line update” training on providing immunisations designed for providers who are already trained, however, I have not completed the initial training course (aimed at registered nurses and pharmacists – as per WA health information from their website). I do hold a bachelor degree in paramedical science, and have participated in consistent on-line and group cpd,; as well as being ALS 2 Qualified.

My new employer has been requesting me to complete the “short on-line update course” and I am told that will be fine, however, I was taught to be cautious and I want to know where I stand in legal terms of providing an immunisation i.e ADT or Twinrix booster whilst only completing the update for already accredited immunisation providers.

I am skilled in IM injection administration; I am well versed in managing life-threatening conditions I.e anaphylaxis; seizures; and other conditions that may be associated with adverse reactions to immunisations; and I have full AHPRA registration; a PRODA Account (to register to update the Australian Immunisation Register). Likewise, for what it’s worth I do have personal liability insurance, although I am by definition an employee.

The administration of an (S4) Immunisation would be over sighted via a telephone consult by an Occupational Medical Doctor where no SASA is in writing (structured administration and supply arrangement).

Could you please advise what is a registered paramedic’s best course of action to take; especially if they are under pressure to complete the “abbreviated update training” within two days, where their new employment may be dependent on having the training done, which may not be in my understanding the correct pathway to be deemed competent under the department of health, especially when applying to update the Australian Immunisation Register (AIR) etc.

The WA health department provides details on ‘Immunisation education’ on its website at https://ww2.health.wa.gov.au/Articles/F_I/Immunisation-education.  That website says

WA Health provides immunisation education to health professionals within the State.

This includes a comprehensive immunisation course for immunisation providers…

The listed courses for health professionals are courses for nurses, midwives and Aboriginal health workers. The website also provides details for recognition of prior learning and ‘Immunisation clinical competency assessment’. The options for RPL is available for ‘Immunisation providers who hold immunisation course certificates from outside Western Australia’.  That is not my correspondent. The option for clinical competency assessment is a tool to ‘assist individuals in identifying levels of competency in their immunisation practice’.  It is not an alternative to an appropriate immunisation course.

The website also provides information on ‘Immunisation Education Update Day webinar series’ and ‘Online immunisation update’.  I infer that it is the ‘Online immunisation update’ that my correspondent has been asked to complete.  The information for that program says:

The Immunisation Update (external site) has been developed by the CDCD [Communicable Disease Control Directorate] and is offered free of charge. Providing WA immunisation providers with this update creates an opportunity for 24/7 access to current immunisation education. The online version creates a solution to the provision of immunisation updates, in an efficient and effective manner to immunisation service providers.

Although nurses with immunisation certification are required to undertake an annual update to maintain their certification, the update is also available to all immunisation providers as a tool to increase immunisation knowledge.

The update comprises of 4 modules including scenarios and quizzes. It will take approximately 4 hours to complete and can be done over multiple sessions.

It seems clear that this is not intended to replace the ‘initial training course’.

On the web page providing ‘Immunisation provider information and resources’ the Department of Health says

The CEO of Health has issued the below SASAs [Structured Administration and Supply Arrangements] to authorise certain Registered Nurses and Midwives to administer vaccines in accordance with the Medicines and Poisons Regulation 2016. Providers who are eligible to work under the relevant SASA are encouraged to familiarise themselves with the requirements.

(The relevant SASAs appear to be:

  1. Registered Nurses – vaccination (Word 91KB)
  2. Midwives – vaccination (Word 90KB) but see also
  3. Pharmacists – influenza vaccination (Word 89KB)).

That means that those nurses and midwives authorised by the SASA can possess, supply and administer the vaccinations on that authority.  This will not extend to my correspondent who is a paramedic but not a nurse nor a midwife.

Twinrix is ‘inactivated hepatitis A and recombinant DNA hepatitis B vaccine’ (https://au.gsk.com/en-au/products/our-prescription-medicines-and-vaccines/vaccines/twinrix/).  Hepatitis A and B vaccines are listed in Schedule 4 of the Poisons Standard (21 December 2018, https://www.legislation.gov.au/Details/F2019L00032).   Schedule 4 poisons are ‘Prescription Only Medicine’ (cl 1.3).

In WA (Medicines and Poisons Act 2014 (WA) s 27):

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 my correspondent was employed by a medical practitioner then my correspondent could possess, supply and administer the medication provided it was the doctor who actually determined that the medication was warranted ie prescribed the medication. However I doubt that my paramedic is actually employed by a medical practitioner.

Assuming that my correspondent’s employer is a ‘health service’ then the health service can issue a SASA authorising my correspondent, as an employed health professional, to carry, supply and administer schedule 4 drugs (Medicines and Poisons Regulations 2016 (WA) r 34 and r 62).   Administration of a schedule 4 drug must be on the direction of a ‘prescriber’ (relevantly a doctor) or in accordance with a standing SASA (rr 15 and 62).

Discussion

That is a long way of saying that:

  1. If my correspondent’s employer is a health service (a term that is not defined) and
  2. If there is in place a SASA authorising my correspondent as a paramedic to administer, possess and supply the schedule 4 immunisation drugs; and
  3. If there is a direction from a prescriber (in the absence of independent authority in the SASA) to administer the immunisation; then

It can be lawfully administered.

But that does not answer the critical question of whether my correspondent is competent to administer the drugs.  My correspondent says

I do hold a bachelor degree in paramedical science, and have participated in consistent on-line and group cpd, as well as being ALS 2 Qualified… I am skilled in IM injection administration; I am well versed in managing life-threatening conditions i.e anaphylaxis; seizures; and other conditions that may be associated with adverse reactions to immunisations; and I have full AHPRA registration; a PRODA Account (to register to update the Australian Immunisation Register).

Paramedic registration under the Health Practitioner Regulation National Law does not define scope of practice.  The Code of Conduct (Interim) issued by the Paramedicine Board (June 2018) says (at [1.2]):

Practitioners have a responsibility to recognise and work within the limits of their competence and scope of practice. Scopes of practice vary according to different roles … To illustrate, in relation to working within their scope of practice, practitioners may need to consider whether they have the appropriate qualifications and experience …

Paragraph [2.2] says:

Maintaining a high level of professional competence and conduct is essential for good care. Good practice involves:

a) recognising and working within the limits of a practitioner’s competence and scope of practice, which may change over time

b) ensuring that practitioners maintain adequate knowledge and skills to provide safe and effective care

c) when moving into a new area of practice, ensuring that a practitioner has undertaken sufficient training and/or qualifications to achieve competency in that area…

The Continuing Professional Development registration standard (17 May 2018, p. 1) says that a paramedic must chose CPD that ‘contributes directly to improving your competence (performance and behaviour) and keeping you up to date in your chosen scope and setting of practice.’

As a registered professional it is up to my correspondent to determine whether he or she is comfortable and feels competent to administer immunisations in accordance with the SASA issued by his or her employer.  If not it is up to the paramedic to raise that with the employer and undertake CPD to gain that competence.  Who pays for that training and on whose time it is completed is a matter for negotiation between the employer and employee.

Conclusion

“The administration of an (S4) Immunisation … over sighted via a telephone consult by an Occupational Medical Doctor” is lawful provided there is an SASA in place to authorise the paramedic to carry, supply and administer the listed medication, albeit administration is on the direction of a doctor.

Whether the ‘short on-line update course’ is sufficient to give the paramedic confidence and competence to administer the immunisation is a matter ultimately for the paramedic who is responsible for his her professional development and scope of practice.

The difference for nurses and midwives is that if they do the courses offered by WA Health they can take advantage of the SASAs issued by the CEO of Health and can independently authorise the administration of the immunisation.