Authorising medicines for specified surgical procedures done by non-veterinarians

How do I go about authorising restricted veterinary medicines for specified surgical procedures that will be done by non-veterinarians?

Introduction

The Animal Welfare (Care and Procedures) Regulations 2018  (the Regulations) permit non-veterinarians to undertake specified surgical procedures , subject to conditions. Many of these procedures require pain relief or local anaesthesia, which can only be authorised by a veterinarian. 

This advice outlines the expectations on veterinarians who authorise restricted veterinary medicines (RVMs) for use by their clients for these procedures on their animals. These same principles apply for situations where veterinarians authorise other people (i.e. staff) to administer RVMs under the veterinarian’s direction. 

This guidance does not apply where Veterinary Operating Instructions are required or where a veterinary student is undertaking a procedure under veterinary supervision.

Background

The veterinary profession has an opportunity to improve the access and use of pain relief for many common procedures performed on animals by non-veterinarians. Improving access and use of pain relief for these procedures will reduce pain or distress (physical and psychological suffering) in animals.

Expectations for authorising RVMs

The ACVM Notice, Requirements for Authorising Veterinarians, specifies the requirements that must be met by veterinarians who authorise restricted veterinary medicines.

Section 5 of the Animal welfare chapter of the Code says:

…Veterinarians must be satisfied that any person under their authority who performs any type of[significant]surgical procedure on an animal is appropriately trained and supervised, and that the animal does not suffer unreasonable or unnecessary pain or distress.

These expectations are triggered when a veterinarian consults with an owner or person in charge of an animal and authorises RVM pain relief or anaesthesia to enable a procedure to be undertaken by a non-veterinarian in compliance with the Regulations (i.e. the correct RVM authorised for a specific person for a specific procedure). This is because, even if the veterinarian is not supervising the person who will perform the procedure, they are enabling them to do it by authorising the RVM. 

Section 3 of the Veterinary medicines chapter of the Code says:

Veterinarians must only authorise RVMs following a veterinary consultation or issuing VOI

The definition of “veterinary consultation” states:

A veterinary consultation must include the veterinarian determining and providing the appropriate level of advice and training so as to be satisfied that the agreed course of action can proceed as planned.

We interpret these requirements in the Code to mean that veterinarians who agree to authorise RVMs for the purpose of a non-veterinarian carrying out a procedure are expected to take reasonable steps to ensure:

1. the RVM is appropriate for the circumstances
2. the person who will administer the RVM is competent to do so, and
3. the person who will carry out the procedure is competent to do so to the extent that the animal welfare outcome is acceptable (this includes the ability to identify when the procedure is and isn’t indicated).

This does not mean that the veterinarian takes on responsibility for the procedure itself. If concerns were raised, questions about the veterinarian’s conduct would focus on whether the veterinarian took reasonable steps to ensure the three points above were met.

Where the veterinarian’s instructions and methods provided during the training are not followed, responsibility would sit with the person undertaking the procedure.

The duty on veterinarians extends to ensuring people undertaking procedures are able to recognise early signs of animal distress, injury or ill-health and to take remedial action or seek help.

RVM Selection

The veterinarian must also consider the varying levels of risk associated with different RVMs (e.g. Lignocaine versus Xylazine) they may be authorising. 

This would include considering (for example):

• the competence of the person to administer the product
• ability to evaluate the risks of sedation to animals and staff
• health and safety risks (e.g. accidental human injection)
• the ability to manage adverse events and the ability to manage risks of diversion for human abuse, and
• management of inappropriate use of the RVM (e.g. a sedative authorised for disbudding being used by the farmer when trimming a cows hoof and accidentally injecting themselves or someone else).

The responsibility sits with the veterinarian to make a reasonable judgement about the above factors. Ultimately the veterinarian will need to decide if it is a good idea to authorise a sedative in this situation.

There is useful guidance about the authorisation of similar products such as controlled drugs in our technical advice on Authorising Controlled Drugs for use by non-veterinarians.

Veterinarians are not obliged to provide RVMs, especially where they have concerns about the non-veterinarian’s competence.

Supervision, competence, and training

The Regulations give general requirements about who is a ‘competent’ person. In relation to the specific procedure they are undertaking they must:

• be experienced, or have received training in, the correct use of the method being used
• be able to recognise early signs of significant distress, injury, or ill-health so that the person can take prompt remedial action or seek advice (e.g. from a veterinarian)
• have suitable equipment, and
• have the relevant knowledge, have received relevant training, or be under appropriate supervision.

Veterinarians are expected to consider what evidence there is, of a person’s competence, including the currency and recency of that person’s training in the correct procedure.

Where a person is not yet competent, veterinarians may elect to provide training in the:

• Procedure to ensure competency, to enable those procedures to be performed safely and humanely to ensure there are acceptable welfare outcomes for those animals
• Competent management and use of RVMs prior to authorising, and
• Recognition of early signs of animal distress, injury, or ill health, including veterinary emergencies and adverse events, and how to engage in that care.

Importantly it is not necessarily the experience, but the procedure being carried out correctly, using appropriate methodology, that determines competence.

Evidence of competency assessments should be supported by training and assessment records, attendance at training events such as an industry training days or online training module etc. Records should also reflect updated training with current techniques and equipment.

Qualifications

Veterinarians may, where appropriate, rely on a person’s qualification to indicate their competence. 

Third parties, who have robust training and assessment methodologies can also provide competency training (e.g. another veterinarian). Training should include currently accepted practices and meet accepted professional and industry standards.

Veterinarians should use their professional judgement, and consider asking other knowledge experts, when considering the quality of the person’s education and experience.

Veterinarian Competence

Veterinarians should work within their area of competence and have the appropriate skills and knowledge in order to be in a position to assess another person’s competence. For example, veterinarians without appropriate knowledge in equine procedures, should not authorise RVMs for procedures on equids.

Emergency care

In any situation where a veterinarian authorises RVMs, they must have arrangements in place to respond where a side effect or adverse event associated with the RVM occurs, and for the surgical procedure undertaken.

Where the owner or person in charge of the animal(s) is a client, that veterinarian is also obliged to provide emergency care. 

Pain relief

Where the Regulations require pain relief to have been administered, it is commonly referred to as follows:

… throughout the procedure the [animal] is under the influence of pain relief that is authorised by a veterinarian for the purpose of the procedure.

The regulations define pain relief: 

pain relief means any anaesthetic, analgesic, or sedation administered with the aim of providing effective and significant alleviation of pain.

Veterinarians are expected to use their judgement when authorising pain relief and, in most circumstances, this will include, at a minimum, local anaesthetic. 

This expectation should not prevent a veterinarian, where they see it as appropriate and/or where it is considered good practice, from authorising the administration of perioperative nonsteroidal analgesics, for use by non-veterinarians, or supervising the use of sedatives, or the veterinary use of general anaesthetics.

Owner Consent

When considering whether a procedure can be delegated to a non-veterinarian, for example to an employee, the veterinarian has a responsibility to obtain the consent of the owner knowing that the procedure will be carried out by a person who is not a veterinarian. 

Veterinarians should advise the clients of the possibility of impacts on the insurance relating to their animal should a procedure be performed by a non-veterinarian.

Veterinarians should also be aware of their own insurance policies and understand what cover is (or is not) provided when they delegate non-veterinarians to undertake a specified surgical procedure.