A paramedic asks:
Can a non-QAS Paramedic administer flu vaccine to patients in Queensland via standing order of his/her company’s Medical Director?
It would seem that most vaccines are listed in Schedule 4 of the Poisons Standard, that is they are prescription only medicine. For example, the following vaccines are all listed in schedule 4: cholera, dengue, GnRH, haemophilus influenzae, hepatitis a and b, human papillomavirus, influenza and coryza, Japanese encephalitis, measles, meningococcal and meningococcal group b, mumps, pneumococcal, poliomyelitis, rabies, rubella, triple antigen, typhoid and varicella.
The legislative regime
Queensland Health says ‘Under the Health (Drugs and Poisons) Regulation 1996 only certain medical professionals are able to administer vaccines.’
QAS paramedics are given authority to obtain, possess and administer scheduled drugs (rr 66, 174 and 174A and appendix 2A). Without going into details of the qualifications required for the drugs, the listed drugs are: amiodarone, atropine, benztropine, box jellyfish antivenom, ceftriaxone, clopidogrel, enoxaparin, frusemide, haloperidol, heparin, hydrocortisone, ketamine, lignocaine, methoxyflurane, metoclopramide, midazolam, morphine, naloxone, nitrous oxide, promethazine, reteplase, salbutamol and tenecteplase. I’m not a pharmacologist but I don’t think any of those drugs are immunisation drugs. It follows that QAS paramedics are in no different position to any other registered paramedic so the answer here will apply to all paramedics whether they are employed by QAS or not.
Regulation 163 says:
To the extent necessary for conducting an immunisation program, an environmental health officer employed by a local government in the program is authorised to possess a vaccine for human use.
Regulation 175(4) says:
To the extent necessary to practise nursing under an immunisation program, an immunisation program nurse is authorised to—
(a) obtain a vaccine or other restricted drug; or
(b) administer a vaccine or other restricted drug under the immunisation program nurse DTP.
There is no similar regulation for paramedics, QAS employees or not.
For the purposes of the Health (Drugs and Poisons) Regulation 1996 (Qld) schedule 4 drugs are called ‘restricted drugs’ (Appendix 9). Medical practitioners are authorised to obtain, possess, administer, dispense or prescribe or supply a restricted drug to ‘the extent necessary to practise medicine’ and where the doctor is of the view that the drug is needed as for a ‘therapeutic use as part of [a] person’s medical treatment’ (r 161(1)). Further, a doctor (r 161(1)(d)) may ‘give someone who may administer or supply a restricted drug an oral or written instruction to administer or supply the drug’. A written instruction can include ‘a standing order signed by a doctor or nurse practitioner and on which the date of the order is shown’.
No endorsement or authority is needed (r 183) (1) ‘to deliver a restricted drug to a person for whom it has been dispensed’ or is endorsement required to
… help another person (an “assisted person”) to take a restricted drug that has been supplied for the assisted person as a dispensed medicine, if—
(a) the assisted person asks for the carer’s help to take the dispensed medicine; and
(b) the carer helps the assisted person to take the dispensed medicine under the directions on the label attached to the dispensed medicine’s container.
Discussion
What I don’t understand is this concept of a ‘standing order’ as if a doctor is entitled to authorise other people to possess, supply or administer a drug; in effect a belief that a doctor can delegate his or her authority under r 161 (relating to s4 drugs) to someone else; they cannot – see Doctors delegating authority to carry drugs (August 20, 2014).
Whilst ‘standing order’ is not defined, a doctor cannot authorise a person to possess a s4 drug ‘just in case’ nor can he or she authorise a person to administer the drug to someone that the delegated person (not the doctor) thinks should have it. Without examining the patient, or at least engaging in a consultation even if via phone or videoconference, the doctor cannot determine whether the drug is necessary for the care of that patient.
A doctor can examine a patient, determine that they need a drug and then give a standing order eg a doctor working in a care facility may determine that the nursing staff should administer a prescribed drug every 4 hours and give a standing order for that ongoing care. That is not the same however of saying in some general sense – I authorise you to carry a vaccine (or any other drug) and if you find a patient that you diagnose, you can then give them the drug.
A service provider may have an endorsement (Health (Drugs and Poisons) Regulation 1996 (Qld) Part 5) to possess, supply and administer scheduled drugs and the authority may be in terms that it extends to anyone approved by the entity’s medical director. The power to delegate is then found in that endorsement, not some general power of doctors to authorise other people to carry drugs. Whether that endorsement extends to vaccinations would depend on the terms of the endorsement.
Application
Can a non-QAS Paramedic administer flu vaccine to patients in Queensland via standing order of his/her company’s Medical Director?
They can if the doctor has examined the patient, determined that the person needs the vaccine ‘for a therapeutic use as part of the person’s medical treatment’ and has prescribed the medication. He or she can then authorise the paramedic to administer that medication and if the vaccine is required say in more than one dose over time, the doctor could give a standing order to authorise all those doses to be administered.
Can a doctor authorise a paramedic (QAS employee or not) to obtain vaccines and give them to patients that the doctor has not seen? No, and even if it were not illegal it would be foolish to authorise people to deliver medication to someone the doctor has not had a chance to consult with, or about.
Whether employees of a company can run a vaccination program with the approval of the company’s medical director would depend not on the fact that the medical director is a doctor, but on the terms of any endorsement issued under Part 5 of the Health (Drugs And Poisons) Regulation 1996 (Qld).
Australian Emergency Law 
As a person who administers vaccinations to paramedics, I do this as a nurse immuniser. I must take leave without pay from the ambulance to be employed as a nurse to by the health department to do it.
An interesting question, a Paramedic operating in QLD that is not QAS could hold and administer an S4 medication, however it must be in line with a poisons approval issued by HARU. The list of medications available to non QAS paramedics is extremely small and does not include vaccines.
I agree that a Paramedic could administer the vaccine if it was on the permit, but as per section 3.3 of Poisons approval; “The scheduled drugs listed in Table 4 of the schedule to this approval must only be administered by a qualified paramedic to a patient following consultation with and on the instruction of a doctor” So a doctor would still be required as per the article.
“The exception to 3.3 is in a clinical emergency which, in the opinion of the registered nurse or qualified paramedic, is either immediately life-threatening or is of such clinical severity and consultation with a doctor is not possible immediately.” The exemptions allowed under the approvals would not apply to a vaccine.
Given the tight control over medications allowed on a poisons approval in QLD it would be unlikely HARU would allow the addition of vaccines to the list of allowed medications.
The alternative that is practiced in the private sector, is where the company Medical Director applies for the company to become a vaccine service provider. This does still require the person to administer the vaccine to be registered in the nursing category.