Clinical roles

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Different clinical roles are needed to provide safe procedural sedation.

Minimum roles required

At a minimum, the following roles are required to be physically present in the room with the patient for every episode of sedation.

Proceduralist: may be the sedationist/airway monitor as well as proceduralist if mild sedation is used (oral or inhalation agents).

Clinician assistant or nominated patient monitor:

  • Clinician to aid proceduralist and sedationist as required.
  • If the sedationist is also the proceduralist, this clinician must possess airway skills, including the ability to perform airway manoeuvres, oropharyngeal airway, nasopharyngeal airway and bag-mask ventilation. This person is responsible for monitoring the patient’s airway, breathing and circulation.

For all episodes of moderate sedation (intravenous opioids or benzodiazepines), an additional clinician must be present who will be the nominated sedationist.

For all episodes of deep sedation (except for very brief procedures in large hospitals, e.g. checking automatic implantable cardioverter defibrillators), an anaesthetist or critical care physician (CCP) must be present who will be the sedationist.

The names of the clinicians undertaking each of these roles should be clearly recorded on the procedure record. Where a clinician undertakes multiple roles, their name should be recorded each time.

More about minimum staffing.

Nominated sedationist

The clinician who is responsible for the administration of the sedative and analgesic medications is the nominated sedation practitioner. This clinician may also be the proceduralist only when mild sedation is used. The name of the sedation practitioner must be recorded.

Sedationists:

  • are clinicians including nursing or medical staff and dentists
  • are required for all episodes of moderate or deep sedation
  • are responsible for administering and prescribing sedative or analgesic medications
  • must possess airway skills (including the ability to perform bag-mask ventilation) and are responsible for monitoring the patient’s airway, breathing and circulation.

For low-risk patients undergoing moderate sedation:

  • the nominated sedationist may be a nurse who administers medication prescribed by the proceduralist
  • nominated medical or dental sedationists do not need to be an anaesthetist/CCP provider for low-risk patients undergoing moderate sedation.

For high-risk patients undergoing moderate sedation:

  • nominated sedationist should be an anaesthesia or CCP provider.

Inadvertent and unanticipated rapid progression from sedation to general anaesthesia may occur. The Australian and New Zealand College of Anaesthetists (ANZCA) recommends that the sedationist retains sole responsibility for maintaining and managing sedation, including monitoring the depth of sedation, physiological variables and the patient’s condition.3

Sedationists require sufficient training to:

Nominated patient monitor (with airway skills)

An appropriately trained clinician, proficient in bag-mask ventilation, must be monitored. Their principal task is to monitor and manage the patient’s airway and cardiovascular system during the episode of procedural sedation. This clinician must not be the proceduralist. The name of the nominated clinician must be recorded.

The nominated patient monitor is responsible for:

  • ensuring the patency of the patient’s airway, and respiratory and haemodynamic status until the procedure is complete
  • completing clinical handover to an appropriate staff member who can manage the patient’s recovery phase.

This clinician should regularly monitor the patient’s conscious state by assessing their response to verbal commands and stimulation. If the patient enters a deeper level of sedation than planned or intended, or if the patient’s airway, respiratory or cardiovascular systems become compromised, the nominated patient monitor must alert the procedural team immediately.

If airway support is required, the nominated clinician must be immediately available to support the patient’s airway until:

  • the level of sedation lightens or the patient’s airway can be safely maintained without support; OR
  • emergency assistance arrives via the local clinical emergency response system (CERS).

Successful airway skills training models are generally supported by senior clinicians from anaesthetic, intensive care or emergency departments.

Clinician assistant

A clinician familiar with local the CERS should be available to assist either the proceduralist or sedationist during procedural sedation. The name of the nominated clinician must be recorded.

If the procedure requires staff to be outside the procedural room for their own safety (e.g. radiation exposure risk), the clinician with airway skills must be immediately available outside the room if not in the procedural room already.

For episodes of deep sedation or for high-risk patients undergoing moderate sedation, an additional staff member will be required.

Assistant to the anaesthetist/CCP

The fourth person required for episodes of deep sedation or for high-risk patients undergoing moderate sedation is the assistant to the anaesthetist/CCP. This is typically an anaesthetic nurse or anaesthetic assistant.

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