Today’s correspondent writes:

… to inquire about the process that needs to be implemented in order for our community-run non-profit organisation (Based in NSW) to enable our Registered Nurses to carry and administer medications such as IM Glucagon, IM Midazolam, IM Ondansetron, GTN, and IV crystalloid fluids during emergency situations at communal events.

We currently have a Medical Advisory Committee in place, which oversees our clinical governance, including policies and procedures. However, we would like to know what steps we need to take to enable our nurses to administer the aforementioned medications to patients during emergencies.

We are wondering whether a standing order could be used to authorize our nurses to administer these medications, or if there are any other methods that we should consider.

The starting point is that you cannot have a ‘standing order’ from a doctor to authorise others to carry scheduled drugs to give out to as yet unidentified patients with as yet unknown diagnosis. Doctors cannot authorise others to carry drugs; if they could there would be no need for the restrictions in the drugs legislation (see Doctors delegating authority to carry drugs (August 20, 2014)).  Take for example Appendix C to the Poisons and Therapeutic Goods Regulation 2008 (NSW) which provides details of ‘Persons authorised to possess and use substances’.  If a ‘medical advisory committee’ or some such could write a standing order to authorise others to carry scheduled drugs there would be no need for most of Appendix C as a doctor employed on a mine site (cl 11) or on the board of the ski patrol (cl 14) could give the relevant authorities.

My correspondent says the relevant staff are nurses and the drugs in question are in the first column below. The second column identifies which schedule of the Poisons Standard (February 2023) the drugs are listed in;

DrugSchedule
Glucagon3
Midazolam4
Ondansetron4
GTN (Glyceryl trinitrate)Schedule 3 when in preparations for oral or rectal use; otherwise Schedule 4
Crystalloid fluidsDo not appear to be scheduled – see for example the Public Summary for Hartmann’s solution.  Specific solutions maybe scheduled but without more information I cannot determine that so I assume they are not scheduled.

We are therefore talking about non-scheduled medication, schedule 3 and 4 drugs. No authority is required to possess or supply a non-scheduled drug. In this context what is important is the practitioner knows what the drug is for, when and how to use it – see Non-scheduled drugs (July 27, 2022).

The Poisons and Therapeutic Goods Act 1996 (NSW) s 4 says the word ‘poison’ means any substance listed in schedules 1, 2, 3, 5, 6 or 7.  The term ‘restricted substance’ means a substances listed in schedule 4. Section 17A(1) says

A nurse is authorised to possess, use, supply or prescribe a poison, restricted substance or drug of addiction for the purposes of the practice of nursing, if:

(a) the nurse ‘s registration has an endorsement of a kind referred to in section 94 of the Health Practitioner Regulation National Law (NSW) that qualifies the nurse to possess, use, supply or prescribe that poison, restricted substance or drug of addiction, or

(b) the nurse is a nurse practitioner who is authorised in writing by the Secretary to possess, use, supply or prescribe that poison, restricted substance or drug of addiction.

A nurse may administer a drug on the direction of a medical or nurse practitioner (Poisons and Therapeutic Goods Regulation 2008 (NSW) r 68C) but that does not mean some general standing order to treat an as yet unidentified patient. A medical or nurse practitioner can only give that sort of direction if they have ‘personally reviewed the patient in person or by audiovisual link’ (s 68B).  This is the clause that allows a doctor to examine the patient and direct a nurse to administer a drug as part of their treatment.

A nurse in charge of a ward also has authority and responsibility for the storage of drugs but that is not relevant in this context.

Conclusion

In the absence of specific permission in either the Poisons and Therapeutic Goods Act or Regulations the community-run non-profit organisation would need to ensure that the nurses on staff are endorsed nurse practitioners, or they would need to apply to the Secretary of Health for an authorisation pursuant to section 17A of the Poisons and Therapeutic Goods Act 1996 (NSW).

This blog is made possible with generous financial support from the Australasian College of Paramedicine, the Australian Paramedics Association (NSW), Natural Hazards Research Australia, NSW Rural Fire Service Association and the NSW SES Volunteers Association. I am responsible for the content in this post including any errors or omissions. Any opinions expressed are mine, and do not necessarily reflect the opinion or understanding of the donors.