Delegation of Cosmetic Schedule 4 Injections

We have been advised that it is a current area of focus for some regulatory bodies as there still appears to be significant confusion regarding this issue.

S4 substances can only be supplied on the written prescription of an authorised medical practitioner. However, in some states, nurse practitioners, midwife practitioners, dentists and optometrists can supply S4 drugs if they are specifically authorised to do so under the relevant state based legislation. A registered nurse can only administer S4 medications under the supervision of a doctor and cannot independently purchase, obtain, administer or supply S4 medicine.

Case history

The NSW Health Care Complaints Commission (HCCC) conducted an investigation into allegations that a doctor had inappropriately delegated cosmetic S4 injections to a nurse.^1,2 It was found that the doctor had failed to supervise the nurse who was performing the cosmetic injections as he did not consult with the patients or prescribe the S4 medications prior to the nurse administering the injections. The HCCC was also of the opinion that it was inappropriate for a medical practitioner to give their name to a supplier to procure S4 medications on behalf of a nurse.²

After consultation with the NSW Medical Council, adverse comments were made to the doctor regarding his arrangements with the nurse.

Discussion

The Cosmetic Physicians Society of Australasia (CPSA) has stated that they are aware that the delegation of cosmetic S4 injections by medical practitioners to nurses is common practice. ¹

As a result of the HCCC decision, the CPSA developed a protocol for the delegation of cosmetic S4 injections (see Table 1). The NSW Medical Council has reviewed this protocol and stated:

This protocol is essentially consistent with the Board’s Code of Professional Conduct and that it contains additional details, specific to cosmetic practice. The Board also stated that the draft protocol sets out a sensible set of circumstances in which medical review should be sought.¹

In addition, the WA Department of Health Pharmaceutical Services Branch has issued an information bulletin regarding the prescribing and administration of botulinum toxin (Botox^®, Dysport^®).³ The bulletin makes it clear that only a medical practitioner or a nurse practitioner (with an approved clinical practice guideline) can prescribe Botox and authorise the administration of Botox to a patient.

Further, it states that an authorised practitioner – after assessing the patient, reviewing the patient’s medical history and conducting a physical examination – may direct a registered nurse to administer Botox to a patient. However, this direction must be in writing and specify the substance and dose to be given, the route and site of the administration, how many times the treatment can be repeated and how frequently it can be repeated. The direction can only be valid for up to 12 months. In addition, this administration or supply of the prescription medication must be recorded in the patient’s clinical records.

The CPSA have also issued a policy regarding so called Botox parties, entitled Cosmetic Injection Party Policy.⁴ This states:

CPSA considers the administration of anti-wrinkle injections or dermal fillers, or the performance of any cosmetic medical procedure in a party setting, to be incompatible with good medical care. The CPSA believes these types of non-invasive and minimally-invasive cosmetic procedures are medical procedures which should be conducted in the appropriate medical setting.

If you have any concerns regarding your current arrangements regarding the delegation of cosmetic S4 Injections to nurses, please contact MDA National’s Medico-legal Advisory Service on 1800 011 255 for assistance.

Sharon Russell
Claims Manager (Solicitor), MDA National

References:
1. Association of Professional Aestheticians of Australia. Injections in Appearance Enhancement.
2. Australian Society of Cosmetic Medicine. Schedule 4 Injector Standards: Update.
3. Department of Health. Medicines and Poisons.
4. Society of Cosmetic Physicians Australia. Cosmetic Procedures.