Minimum standards for safe procedural sedation

Sedation is safest for healthy patients. The pre-sedation assessment determines a person’s suitability for sedation and the depth of sedation needed.

Pre-sedation screening identifies patients whose health status means they may need more highly specialised sedation providers. A patient’s health status for anaesthesia is determined by a risk assessment in combination with their American Society of Anesthesiologists (ASA) score.

Typically, the risk assessment is performed by the procedural sedation provider or a suitably trained clinician acting under their supervision.

Assessment factors

Pre-sedation risk assessment takes into account the intended depth of sedation (mild, moderate or deep), as well as patient, airway and procedural factors.

For planned procedures, complete assessments before the day of the procedure. This allows time to identify the patient’s needs, provide instructions and organise any required referral for anaesthesia or physician-led sedation.

ASA score

The ASA score is a global tool for classifying the physical status of the patient. It is also referred to as ASA-PS.

Every patient undergoing sedation should have an ASA score attributed to them by the person conducting the risk assessment.

Every sedation provider should know the patient’s ASA score if providing moderate or deep levels of sedation.

Patients with an ASA score of 1 or 2 are considered healthy.⁷ Risk increases exponentially with increasing ASA score.

ASA 1: a normal healthy patient

ASA 2: a patient with mild systemic disease

ASA 3: a patient with severe systemic disease

ASA 4: a patient with severe systemic disease that is a constant threat to life

ASA 5: a patient who is not expected to survive.⁸

References

1. Australian and New Zealand College of Anaesthetists. PG09(G) Guideline on procedural sedation 2023. Melbourne, Australia: ANZCA; 2023 [cited 5 December 2024].
2. Dobson G, Chong MA, Chow L, et al. Procedural sedation: a position paper of the Canadian Anesthesiologists' Society. Can J Anaesth. 2018;65(12):1372-84. DOI: 10.1007/s12630-018-1230-z
3. Tran TT, Beutler SS, Urman RD. Moderate and deep sedation training and pharmacology for nonanesthesiologists: recommendations for effective practice. Curr Opin Anaesthesiol. 2019;32(4):457-63. DOI: 10.1097/aco.0000000000000758
4. Green SM, Roback MG, Krauss BS, et al. Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline. Ann Emerg Med. 2019;73(5):e51-e65. DOI: 10.1016/j.annemergmed.2019.02.022
5. Uí Bhroin S, Kidney E, Sabbagha H, et al. Procedural Sedation of Adults in the Emergency Department [v1.0]. Irish Association for Emergency Medicine (IAEM); 2022.
6. Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018: A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. Anesthesiology. 2018;128(3):437-79. DOI: 10.1097/aln.0000000000002043
7. Kim SH, Moon YJ, Chae MS, et al. Korean clinical practice guidelines for diagnostic and procedural sedation. Korean J Anesthesiol. 2024;77(1):5-30. DOI: 10.4097/kja.23745
8. American Society of Anaesthesiologists. Statement on ASA Physical Status Classification System. Washington D.C., United States: ASA; 2020 [cited 12 February 2025].

Risk stratification identifies patients who are at risk of sedation-related adverse events so they can be referred to a more highly specialised sedation provider.

Risk stratification focuses on the degree of sedation required and may be unnecessary for procedures performed with mild sedation. Find more information in the Safe Procedural Sedation Matrix.

In higher volume services, a dedicated person will provide screening to enable safe and efficient care.

The screener will alert clinical staff when patients do not meet the agreed criteria for non-anaesthetist procedural sedation. This should then be followed up with a nominated contact within the department of anaesthesia for advice and referral.

Flag system

A flag system can be used to alert staff to higher risk patients.

Red flags represent the highest risk for procedural sedation. They indicate a contraindication to sedation performed without specialised anaesthesia or critical care providers (CCP). Patients should be carefully evaluated for red flags and, if any are identified, they should be referred to anaesthesia- or CCP-led sedation.

Orange flags represent patients at increased risk and should be identified before episodes of moderate sedation. The presence of a greater number of orange flags represents an additive patient risk for sedation.

Local policies should determine what happens when multiple orange flags are identified. For example, the presence of three orange flags may mean that sedation is performed by an anaesthesia or CCP provider. At a minimum, patients with multiple orange flags should be discussed with a nominated contact at the department of anaesthesia for advice and consideration for referral.

Stratification

Consider depth of sedation and orange and red flags when assessing risk.

Pre-Sedation Risk Assessment Flow Chart

Anaesthesia or CCP-led sedation should be strongly considered for:

• planned deep sedation
• procedures >120 minutes
• procedures with prolonged moderate or severe discomfort
• uncomfortable positioning during procedure
• previously failed sedation
• patients in whom benzodiazepines or opioids are contraindicated
• uncooperative patients
• patient unable to lie flat or remain still for the procedure.

The pre-sedation risk assessment and decision guidance provides an example of how risk assessment can be undertaken, to take both depth of sedation and orange or red flags into consideration.

• Red flags for mild sedation
• Red flags for moderate sedation
• Orange flags

Patients should be properly prepared before a procedure to ensure safe sedation.

Consent

Informed consent requires shared decision making between the healthcare team, the patient and their family or carers. It is the patient's decision to agree to the procedure, and the patient can give or withdraw consent at any time.

This acknowledgement can be verbal and documented in the clinical notes. However, if significant risks are identified, they should provide written consent.¹

Consent must take place after the patient has:

• received accurate and relevant information about the surgery or procedure, and other treatment options
• adequate knowledge to consider the benefits and risks of the surgery or procedure
• considered what to do if there are any complications
• collaboratively discussed their goals and wishes.²

Considerations:

• If a patient is unable to give consent, obtain consent from an appointed guardian or a person responsible.³
• An interpreter is essential for a patient who does not speak or read English.
• Consent must be documented.⁴
• Patients should be informed that they may have some recollection of the procedure if undergoing mild or moderate sedation.

Resuscitation plan

Where a patient has a resuscitation plan, this must be reviewed with the patient, person responsible and proceduralist to determine whether it is appropriate to suspend it during the intra- or post-procedural period. This decision must be clearly documented in the medical record.

Reviewing or reinstating the resuscitation plan should be discussed with the patient at an appropriate time following the procedure.

Fasting

All patients must be appropriately fasted before their procedures to reduce harm from pulmonary aspiration.

This should be in accordance with current standards or local policy, which may include Sip Til Send protocols. This may need modification in specific circumstances, i.e. glucagon-like peptide-1 receptor agonists.

Fasting may not be required for some patients undergoing mild sedation.

Medication

Give patients clear preoperative medication instructions. Carefully manage people using diabetic and anti-thrombotic medications.

Restraint

Restraint must only be used as a last resort after less restrictive alternatives have been trialled and considered, and only if the patient is in danger of hurting themselves or others.

References

1. NSW Ministry of Health. Consent to Medical and Healthcare Treatment Manual – Section 4 – Requirements for consent.NSW, Australia: NSW Ministry of Health; 30 Apr 2025 [cited 12 Aug 2025].
2. Australian Commission on Safety and Quality in Health Care. Informed consent. Sydney: ACSQHC;  2024 [cited 12 Aug 2025].
3. NSW Civil and Administrative Tribunal. Consent to medical or dental treatment. NSW, Australia: NCAT; 8 Sep 2022 [cited 12 Aug 2025].
4. Vogel A, Guinemer C, Fürstenau D. Patients' and healthcare professionals' perceived facilitators and barriers for shared decision-making for frail and elderly patients in perioperative care: a scoping review. BMC Health Serv Res. Feb 24 2023;23(1):197. DOI: 10.1186/s12913-023-09120-4

Sedation providers target a level of sedation based on a range of procedural and patient factors.

The patient, sedation provider and proceduralist should discuss this before the procedure to set clear expectations.

Assessing sedation

During the procedure, clinicians will monitor the patient's level of sedation.

One tool used to do this is the Modified Ramsay Sedation Scale, which assesses the level of sedation using a patient's responsiveness to verbal and tactile stimulus.

Adapted with permission from: Pharmacokinetics and Pharmacodynamics of Orally Administered Clonidine

Deep sedation

Anticipate the possibility of inadvertent progression to a deeper level of sedation than intended. Intentional deep sedation should be avoided by non-anaesthetists.

On occasion, a patient’s inability to accept or tolerate a procedure with conscious sedation (mild to moderate sedation) will necessitate referral to the anaesthesia department.

It is always safer to give a small dose and observe the effect by checking the patient’s response to voice, touch or a mildly painful stimulus, for example, jaw thrust. This is especially important in older patients, who often exhibit a more pronounced and prolonged response even to low doses. This requires a longer observation period before further dosing.

Clinicians who administer sedation or monitor sedated patients need a working knowledge of the actions, interactions and adverse effects of commonly used medications.

This involves the pharmacology of medications including benzodiazepines and opioid drugs, as well as reversal agents.

Procedural units provide information on:

• their local preferred sedative agents
• standard dosing arrangements
• maximum dosing arrangements
• local clinical emergency response system (CERS) process
• reversal agents, which must be readily available.

This information should be available to the clinical team in a summary sheet.

Interactions with the patients’ regular medications must also be considered.

Before sedation, the sedation plan should be discussed with the clinical team, including the agent, dosage, potential issues and the plan for escalation. The plan should include an upper limit, or ceiling, so that excessive doses are not administered. For example, a typical ceiling for drugs such as midazolam might be 5 milligrams and fentanyl 100 micrograms.

Propofol

Propofol is most frequently used to produce deep sedation or general anaesthesia and carries additional risks of increased respiratory depression, airway obstruction and hypotension. It should only be administered by trained and credentialed users who are experienced in its use.

Intentional deep sedation should only be provided by an anaesthetist, critical care physician (CCP) or other practitioner within their scope of practice.

Propofol or remifentanil infusions should only be used by anaesthetists or CCPs.

Propofol boluses should only be used if there is a separate sedationist and proceduralist, with minimal staffing of 4 people, and local policies allow its use.

Other jurisdictions within Australia have introduced endoscopist-directed nurse-administered propofol sedation. We will continue to monitor the progress and outcomes of these programs with the view to potential introduction in the future if supported by evidence.

Other agents

Facilities should develop local guidelines and credentialing if other drugs are to be used.

For inhaled nitrous oxide and methoxyflurane, adhere to protocols for patient and staff safety. NSW Health provides guidance on the provision of nitrous oxide in NSW health facilities.

Where possible, clinical staff should have access to a locally supported credentialing or knowledge program. Several procedural units have successfully developed and implemented credentialing programs for pharmacology awareness.

All NSW Health clinical staff must complete basic life support training. For clinicians working in a setting where procedural sedation is performed, this should be supplemented by more detailed training and support.

The Clinical Excellence Commission provides guidance on life support training requirements.

Clinicians who administer sedation must have adequate knowledge and skills to detect and manage serious adverse effects of procedural sedation. This requires more detailed training in addition to basic life support, and, where relevant, advanced life support.

Common adverse effects

Clinicians require life support skills to detect and manage the most common serious adverse side effects of procedural sedation.

Clinicians should have access to an appropriate airway skills training and credentialing program. Procedural units have successfully developed and implemented credentialing programs for airway skills. Across hospitals, local health districts and specialty networks, this training is supported by a range of senior clinicians from anaesthetic, intensive care or emergency departments.

Patients are monitored throughout the procedure and during recovery.

All patients receiving intravenous sedation must have:

• continuous waveform pulse oximetry to monitor heart rate and oxygen saturation, with appropriate audible patient alarms
• regular monitoring of blood pressure throughout the procedure (every 5 minutes at a minimum)
• oxygen and equipment to deliver supplemental oxygen via high flow, nasal prongs or mask
• capnography and electrocardiogram (ECG) immediately available, in case it's needed
• capnography in cases of moderate sedation, especially where there is risk of unintended deep sedation (includes all occasions where propofol is used)
• regular observations, including the level of sedation, recorded on an appropriate sedation record.

Observations should be recorded in an intra-procedure sedation record.

The Australian and New Zealand College of Anaesthetists (ANZCA) recommends intra-procedure records are maintained as near to the timing of administration of medications as possible. Regular readings should be maintained during the intra-procedure and recovery phase.

Access to the correct equipment is essential to safe procedural sedation.

Intravenous, patient monitoring and emergency equipment are required for every episode of procedural sedation.

Intravenous equipment:

• Intravenous access

Monitoring equipment:

• Pulse oximeter
• Non-invasive blood pressure
• Capnography
• Electrocardiogram (ECG)

Emergency and other equipment:

• Cannulation equipment
• Oxygen
• Oropharyngeal suction
• Emergency equipment, including a defibrillator and drugs used for cardiac arrest
• A means to inflate the lungs with 100% oxygen, such as a self-inflating bag and waters circuit (Mapleson C) or T-piece and suitable sizes of face mask
• Equipment to assist in airway management, e.g. oropharyngeal and nasopharyngeal airways, laryngeal mask airways, a range of laryngoscopes and endotracheal tubes

When opioids or benzodiazepines are the principal sedatives, their reversal agents should be readily available.^1–3

Atropine or glycopyrrolate should be available to treat bradycardias and ephedrine or metaraminol (in suitable dilution) to treat hypotension if severe (SBP < 80 mmHg), along with cessation of sedative drug administration.

References

The ability to recognise and manage complications is fundamental to providing safe sedation.

Providers must be suitably trained and competent to identify, prevent and manage complications that arise during episodes of procedural sedation.

Potential risks

The sedation continuum describes a dose-dependent depression of the patient’s level of consciousness and cardiorespiratory systems. Sedative and analgesic medications should be administered at the lowest effective dose necessary to achieve patient comfort while minimising the risk of adverse events.

Some patients are particularly susceptible to the effects of sedative or analgesic medications, and different medications have different margins of safety. Sedative and analgesic medicines work synergistically, i.e. one drug may exacerbate the intended and adverse effects of the other.

Transition from sedation to deep unconsciousness, with the risk of losing protective reflexes, may occur rapidly and unexpectedly.¹

Clinicians who administer sedative or analgesic drugs, and who supervise recovery from sedation, must be prepared to manage the following potential risks:

• Depression of protective airway reflexes and loss of airway patency.
• Depression of respiration or hypoxaemia.
• Depression of the cardiovascular system.
• Adverse drug reactions including anaphylaxis.
• Unexpectedly extreme sensitivity to the drugs used for procedural sedation or analgesia resulting in unintentional loss of consciousness, and respiratory or cardiovascular depression.

All staff must comply with pre-procedure and post-procedure requirements as outlined in the NSW Health Clinical Procedure Safety Policy (PD2025_006).

Warning signs

Red flags for action by the team include:

• unexpected reduction in the patient’s conscious state beyond the target sedation level
• snoring or noisy breathing – these are signs of partial obstruction and can rapidly progress to complete obstruction
• signs of regurgitation of gastrointestinal contents
• hypoxaemia – detected by pulse oximetry
• complete airway obstruction – may be silent
• paradoxical chest movement – may indicate partial or complete obstruction
• unexpected patient agitation
• hypotension
• cyanosis is a late sign of deterioration.

Clinical emergency response system

The clinician monitoring the airway should be trained to recognise patient deterioration, and must be able to activate the local clinical emergency response system (CERS).

In NSW, the need for emergency assistance should align with the NSW Health Standard Observation Charts and local CERS as outlined in Recognition and management of patients who are deteriorating (PD2025_014). If emergency trigger observation levels need to be changed, document the variations before the procedure and ensure the proceduralist and nominated patient monitor agree on them.

Any patient deterioration outside prescribed or agreed limits will trigger the local CERS. All team members must be aware the procedure needs to pause or cease in the event of patient deterioration. The team member with bag-mask ventilation skills will attend the patient’s airway until the arrival of the CERS team.

The process for escalating to the CERS should be determined by local operating procedures.

Skills required

In addition to the clinical skills outlined above, non-technical and teamwork skills are essential:

• Team briefings and structured communication skills, including effective handover. Conduct team huddles or briefings at the start of procedure lists or individual procedures. Led by the senior clinician, they should include overt permission for all staff to speak up if any issue is perceived. This also provides an opportunity to clarify roles.
• Closed loop communication. This is especially relevant for the administration of drug doses where both the amount (in milligrams and micrograms) and volume of drugs should be requested by one team member and confirmed to be given by another.
• Mutual performance monitoring and shared mental models to maintain situational awareness. This is especially important should an adverse event occur.
• Speaking up techniques such as graded assertiveness. Models such as PACE (probe, alert, challenge, emergency action) or CUSS (concern, unsure, safety, stop) should be available.
• Role clarity.
• Use of protocols and cognitive aids.²

More about access to support and training

References

1. Australian and New Zealand College of Anaesthetists. PG09(G) Guideline on procedural sedation 2023. Melbourne, Australia: ANZCA; 2023 [cited 5 December 2024].
2. Salas E, Sim DE, Burke CS.  Is there a “Big Five” in Teamwork? Small Group Research 2005; 36:555. DOI: 10.1177/1046496405277134

Procedural sedation is when analgesic or low-dose anaesthetic medications are used to allow patients to tolerate uncomfortable or painful procedures.

Sedatives may be given orally, via inhalation, intranasally (IN), intravenously (IV) or intramuscularly (IM).

As a greater number of complex procedures are being performed outside operating theatres, the need for safe procedural sedation continues to increase.

Ideal safe sedation journey

Pre

• Patient is assessed.
• Risk stratification establishes whether an anaesthetist should be consulted.

Intra

• Patient is sedated by a trained clinician.
• Patient is monitored during the procedure by clinician (not the proceduralist).
• Clinician is present with bag-mask ventilation skills.
• Responsibility and accountability for the patient is handed over.

Post

• Patient is monitored during recovery phase.
• Patient is assessed for discharge and follow-up arranged.
• Patient is discharged and accompanied by responsible adult.

Safety

Patient safety is underpinned by individual patient risk assessments, risk stratification and management, safe medication use, and access to life support skills and resources.

Anaesthetists, including rural generalist anaesthetists and critical care physicians (CCPs) are specifically trained to manage patients under sedation; however, they are not required or available for every sedation episode, especially for low-risk patients.

All clinicians who administer and support procedural sedation must be appropriately trained to manage potential complications.

In NSW public hospitals, there are several specialty areas where sedation is routinely administered by non-critical care clinicians.

Levels of sedation

Sedation is classified into three levels: mild, moderate and deep.^1,2

The Australian and New Zealand College of Anaesthetists (ANZCA) define these as follows:³

• Mild: a drug-induced state of diminished anxiety, during which patients are conscious and respond purposefully to verbal commands or light tactile stimulation.
• Moderate: a drug-induced state of depressed consciousness during which patients retain the ability to respond purposefully to verbal commands and tactile stimulation.
• Deep: a drug-induced state of depressed consciousness during which patients are not easily roused and may respond only to noxious stimulation.

In contrast, general anaesthesia renders a reversible state in which a patient is unrousable and unconscious.

The transition between levels of sedation, particularly between deep sedation and general anaesthesia, can be subtle, with a potentially narrow margin of safety. Progression from deep sedation to general anaesthesia can be rapid and unpredictable.³ Clinicians administering sedation must be equipped with the skills and training to safely rescue a patient who enters a deeper level of sedation than intended.

Intentional deep sedation should only be administered by an anaesthetist, CCP or other medical practitioner trained and credentialed to deliver deep sedation within their scope of practice.

Who provides sedation

There are four categories of sedation providers.

All sedation providers, including nurses, dentists, career medical officers, rural generalist anaesthetists, specialist anaesthetists, CCPs, paramedics and their supervised trainees must be appropriately trained, assessed and credentialed within the facility, working within their scope of practice and indemnified for complications arising from sedation.

Summary of recommendations

Notes

1. Fasting is recommended for patients with targeted moderate sedation as escalation to deep sedation is possible. Follow Sip-Til-Send or standard protocols. Risk assessment detects patients with delayed gastric emptying, e.g. on Ozempic, who should be referred to anaesthetist or CCP.
2. Red flags indicate patients who should not be sedated by non-anaesthetists/CCPs. See Standard 1 for list of red flags.
3. Escalation must be available for all patients where moderate or deep sedation is targeted. This can be via and available anaesthetist/CCP or via a MET, clinical emergency response system or rapid response team.
4. Drugs used for sedation can be used by many routes. Commonly oral, IV, IM, IN, inhaled. The key is the sedation achieved (mild, moderate or deep) and not the drug used. In general, lower doses of a drug will cause milder levels of sedation; however, there is wide variability in patient response to standard doses. Low doses in some can produce a deeper level of sedation than expected.
5. All anaesthetists, CCPs, their supervised trainees and rural generalist anaesthetists are credentialed for all three levels of sedation. If other clinicians, e.g. dentists and nurses, have been trained and assessed, they can also provide the appropriate level of sedation, as per their facility credentialing. All providers must be indemnified for complications arising from sedation.
6. Propofol can be used for all three levels of sedation; however, use should be limited to anaesthetists and CCPs, unless an individual has been specifically credentialed in its use.

References

1. Kim SH, Moon YJ, Chae MS, et al. Korean clinical practice guidelines for diagnostic and procedural sedation. Korean J Anesthesiol. 2024;77(1):5-30. DOI: 10.4097/kja.23745
2. Benzoni T, Cascella M. Procedural sedation. Treasure Island, Florida: StatPearls Publishing; Jan 2024 [cited 5 December 2024].
3. Australian and New Zealand College of Anaesthetists. PG09(G) Guideline on procedural sedation 2023. Melbourne, Australia: ANZCA; 2023 [cited 5 December 2024].
4. Salas E, Sim DE, Burke CS.  Is there a “Big Five” in Teamwork? Small Group Research 2005; 36:555. DOI: 10.1177/1046496405277134
5. Dobson G, Chong MA, Chow L, et al. Procedural sedation: a position paper of the Canadian Anesthesiologists' Society. Can J Anaesth. 2018;65(12):1372-84. DOI: 10.1007/s12630-018-1230-z
6. Tran TT, Beutler SS, Urman RD. Moderate and deep sedation training and pharmacology for nonanesthesiologists: recommendations for effective practice. Curr Opin Anaesthesiol. 2019;32(4):457-63. DOI: 10.1097/aco.0000000000000758

Minimum requirements for safe sedation are outlined in the tables below.

Resourcing by setting

Minimum staffing by type of sedation

Patient factors

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:

• fulfil the knowledge and skills outlined in ANZCA PG09(G) Appendix IV Safe procedural sedation competencies
• monitor levels of consciousness and cardiorespiratory status
• detect and manage any complications arising from sedation
• communicate effectively with proceduralists.³

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.

Governance is the shared responsibility of all service providers.

All units, hospitals, local health districts (LHDs) and specialty networks (SNs) must have governance and reporting processes to support sedation. This is in accordance with the requirements in the NSW Health Clinical Procedure Safety Policy (PD2025_006).

Hospitals, LHDs and SNs must also provide the appropriate resourcing to support safe procedural sedation. This may include facilitating and developing relationships between procedural departments and anaesthetic departments or other departments with expertise in sedation practice (where collaboration with an anaesthetic department is not possible).

When establishing a governance process, the scope of practice for clinicians (medical and nursing) should be determined locally in collaboration with procedural units and the anaesthetics department.

Where necessary, credentialing requirements should be identified, documented and implemented.

Accountabilities

Safe procedural sedation practice must be supported by the following:

• Clinicians are responsible for pre-procedure assessment, maintenance of skills and registration, addressing standards, and leading responses to, and reporting of, critical events.
• Unit managers are responsible for ensuring appropriate staffing, equipment and space are available.
• Manager or department head is responsible for ensuring the processes to support safe procedural sedation are followed.

Local policies on procedural sedation should be developed by LHDs and SNs.

The NSW Health Clinical Governance in NSW Policy (PD2025_032) outlines the requirements for effective clinical governance to ensure the best clinical outcomes possible.

Audit and review

Units and teams who regularly administer procedural sedation should have regular and effective audits of sedation-related outcomes. LHDs and SNs should review compliance with local policy, procedures and identified outcomes using 1% of procedures undertaken each month.

Reporting of all adverse outcomes relating to procedural sedation must occur through the ims+ process. This includes, but is not limited to:

• airway compromise requiring intervention
• abandoned procedures
• the need for emergency assistance (rapid response)
• unplanned overnight admission or unplanned admission to intensive care/close observation units
• use of reversal agents.

In particular, frequent use of reversal agents such as naloxone and flumazenil should be reviewed as a potential indicator of suboptimal sedation practice.¹

Local audits may also include patient complaints.

The results of audits should be discussed within the procedural team and inform ongoing training, education and support for all members of the team involved in administering sedation and the care of sedated patients.

Audit and feedback should involve oversight by, and communication with, an appropriate department, for example the clinical governance unit.

Reporting requirements

Clinicians who administer sedation must be familiar with their jurisdictional requirements for reporting all deaths that occur during sedation or within 24 hours following its administration.

Sedation-related deaths occurring beyond the 24-hour window must still be reported to the Special Committee Investigating Deaths Under Anaesthesia (SCIDUA), irrespective of when the death occurs, e.g. death on day five due to severe aspiration during sedation.

More information about the process for reporting to the SCIDUA can be found on the Clinical Excellence Commission website.

The NSW Health Incident Management Policy (PD2020_047) provides direction for managing and  responding to clinical and corporate incidents, and acting on lessons learned. This complies with the Health Administration Act 1982.

All staff are responsible for identifying incidents and for taking immediate action to ensure the safety of patients, visitors and other staff.

References

1. National Patient Safety Agency. 2008. Rapid Response Report: NSPA/2008/RRR011: Reducing risk of overdose with Midazolam injection in adults.

Strong professional relationships and high-quality training support safe procedural sedation.

Skilled support

Units and departments with well-functioning procedural sedation services usually have collaborative relationships with their local anaesthesia department (where one exists).

A nominated procedural sedation contact within the anaesthesia department (or other department with specialised skills) can assist with developing and updating the triage and risk assessment processes, and locally agreed referral criteria.

If this contact person is not the head of the anaesthesia department, the explicit support of the department head should be sought.

Training

In settings where non-anaesthetist sedation is regularly administered, units and departments should access high-quality training to ensure safe and effective monitoring and management of sedated patients.

Training should include skills in the following areas:

• Knowledge
  • Processes that should occur along the patient journey
  • Equipment used in normal sedation and for airway emergencies
  • Pharmacology of drugs used
• Skills: airway skills and use of airway adjuncts
• Affective: human factor skills and attitudes

In many hospitals, this training is provided by anaesthesia departments via simulation-based training or regular rotation of staff to operating theatres or recovery units.

If anaesthetic departments are unable to provide training, it may be provided by other critical care teams, e.g. from the emergency department or intensive care unit.

High-quality training is:

• delivered by appropriately trained and skilled clinicians to support the achievement of learning outcomes
• interactive and multidisciplinary
• of sufficient duration to enable participants ample time for hands-on practice with real-time coaching and feedback from facilitators to ensure good airway management technique
• inclusive of the learning outcomes outlined in ANZCA PG09(G) Appendix IV Safe procedural sedation competencies via a combination of reference materials (pre- or post-course reading), small-group learning sessions, skills training and, where feasible, mannequin-based immersive simulation
• delivered with an adequate number of instructors for the group size, e.g. group size of 8–12 requires at least 2–3 instructors
• assessed using participant feedback
• delivered by providers with quality assurance and quality improvement processes in place to drive quality and ensure the training is relevant and up to date.

Anaesthetist – For the purpose of these standards, the term anaesthetist refers to specialist anaesthetists, GP anaesthetists and rural generalist anaesthetists.

CCP – Critical care physician refers to intensive care or emergency medicine physicians.

CERS – Clinical Emergency Response System.

General anaesthesia – A drug-induced state of unconsciousness characterised by absence of purposeful response to any stimulus, loss of protective airway reflexes, depression of ventilation and disturbance of circulatory reflexes.

Procedural sedation – A state of drug-induced relief of anxiety or tolerance of uncomfortable diagnostic or interventional medical, dental or surgical procedures.

Proceduralist – Any practitioner or dentist or dental specialist performing surgical, diagnostic or dental procedures.

Sedationist – Any practitioner, dentist or dental specialist registered with their jurisdictional regulatory registration authority who is responsible for the administration, management and conduct of sedation working within their defined clinical scope of practice.

Sedation levels

Mild – A drug-induced state of diminished anxiety, during which patients are conscious and respond purposefully to verbal commands or light tactile stimulation

Moderate – A drug-induced state of depressed consciousness during which patients retain the ability to respond purposefully to verbal commands and tactile stimulation.

Deep – A drug-induced state of depressed consciousness during which patients are not easily roused and may respond only to noxious stimulation.

These standards outline the key components of safe procedural sedation to support NSW public health services to provide high-quality patient care.

While many of the principles in this guide represent good procedural sedation practice, the standards are not intended to be used in certain specialised settings such as the pre-hospital environment, intensive care units (ICU), close observation units, birthing suites, paediatrics or for the management of patients with severe behavioural disturbance requiring restraint.

The standards are applicable to all modes of sedation – oral, inhalational, intravenous, intramuscular and intranasal – and are intended to be used in conjunction with local protocols.

These standards have been developed for NSW public hospitals, but the general principles, reflecting best practice, are applicable to all clinical settings. As such, they may provide a useful guide for other facilities in NSW, including private settings.

The standards comply with the NSW Health Clinical Procedure Safety Policy (PD2025_006) and are aligned with the Australian and New Zealand College of Anaesthetists Guideline on procedural sedation 2023. These standards should be referred to for mild or moderate sedation, however, the practice of deep sedation falls outside its scope.

Recommendations for the training and accreditation required to be a sedation provider are outside the scope of these standards, as is any course content and the certification of such courses or facility credentialing.

Patients requiring emergency (or unplanned) procedures (outside of the operating theatre, ICU and emergency department) require an assessment to determine whether an anaesthetist or critical care physician (CCP) is required.

Patients with conditions posing an immediate threat to life or limb must have a CCP present, or immediately available.

Patients who are fasted, stable and otherwise well but appear on the “emergency” list can receive standard care.

Acknowledgements

Thank you to the following individuals who were involved in the development of this resource.

• Christian Abel, Radiologist, Hunter New England LHD
• Rummana Afreen, Staff Specialist, Western Sydney LHD
• Deidre Brogan, Clinical Nurse Consultant, Sydney Children's Hospitals Network
• Alexandra Buchanan, Visiting Medical Officer Anaesthetist, Sydney LHD
• Megan Budek, Clinical Nurse Consultant, Nepean Blue Mountains LHD
• Nick Burgess, Clinical Director Gastrointestinal Endoscopy and Senior Staff Specialist Gastroenterologist, Western Sydney LHD
• Deborah Burrows, District Clinical Nurse Consultant Perioperative Services, Southern NSW LHD
• Mavis Chan, Clinical Nurse Educator Endoscopy, Western Sydney LHD
• Megan Courtney, District Clinical Nurse Consultant Perioperative Services, South Western Sydney LHD
• Melinda El-Melki, Clinical Nurse Educator, Northern Sydney LHD
• Scott Fortey, District Director Anaesthesia and Specialist Anaesthetist, Central Coast LHD
• Richard Halliwell, Anaesthetist, Western Sydney LHD
• Kenneth Harrison, Senior Staff Specialist Anaesthetics, Western Sydney LHD
• Giselle Hollinshead, Consumer contributor
• Shangeetha Kumaresan, Emergency Medicine Specialist, South Western Sydney LHD and Sydney Children’s Hospitals Network
• Louise Mackie, Clinical Nurse Educator, Nepean Blue Mountains LHD
• Candice Maher, Acting Perioperative CNC / CNE Operating Theatres, Western NSW LHD
• Ann Marie McCallum, Specialist Anaesthetist, Western Sydney LHD
• Cate McIntosh, Conjoint Associate Professor, Director Hunter New England Simulation Centre
• Brianna Mitchell, Clinical Nurse Specialist Radiology, Sydney LHD
• Benjamin Piper, Specialist Anaesthetist, Hunter New England LHD
• Lucy Ramon, Senior Staff Specialist Rehabilitation Physician, South Eastern Sydney LHD
• Sophie Rayner, Cardiology Clinical Nurse Consultant, Sydney LHD
• Brad Sheridan, Staff Specialist Anaesthetist, Hunter New England LHD
• Ashlee Shoard, Nurse Educator Medical Imaging Services, Illawarra Shoalhaven LHD
• Arpit Srivastava, Anaesthetist, Northern Sydney LHD
• Stuart Thomas, Cardiologist, Western Sydney LHD
• Bradley Wilsmore, Staff Specialist Cardiologist, Hunter New England LHD

Local and NSW Health policies and procedures inform sedation care. There are specific considerations for some patient cohorts.

NSW Health aims to provide quality health services that are accessible, non-discriminatory and equitable. Patient groups requiring supports and adjustments:

• Aboriginal patients
• Culturally and linguistically diverse patients
• Patients with intellectual disability
• Rural and regional patients

Aboriginal patients

Healthcare services should be culturally relevant and safe. They should empower and actively involve Aboriginal families and carers in decision making. Sedation providers and their teams should:

• use shared decision making resources for Aboriginal people and their healthcare professionals to make decisions together, such as the ‘Finding your way’ shared decision making model
• coordinate with local health services or a patient’s usual doctor or healthcare worker to provide preoperative services close to home and on Country for rural and remote locations
• engage Aboriginal health workers or Aboriginal liaison officers, where available, to foster understanding and trust and help coordinate care; for example, attendance at pre-admission clinics and travelling to hospital.

Deliver culturally safe care for Aboriginal patients. Take the time to yarn about treatment options, including the benefits, risks and longer-term implications of treatment decisions. Ensure the patient and their family or support network are meaningfully involved in a shared decision-making process. Conversations should be guided by cultural protocols and communication preferences, using plain language and culturally appropriate resources.

Providing patient-centred care requires a respectful understanding of cultural values, beliefs and communication preferences. Where possible, coordinate care for Aboriginal patients so they can receive investigations, assessments and treatments closer to, or on, Country; and engage local Aboriginal health and social work teams.

Some Aboriginal patients use alternative medicines as part of their healing practices. Maintain flexibility and sensitivity to Aboriginal healing practices through open communication with the entire health team.

Culturally and linguistically diverse patients

NSW Health supports culturally responsive care that recognises and respects linguistic and cultural needs. This commitment includes providing access to care and supporting health literacy to enable shared decision making.

When supporting culturally appropriate care for a patient from a culturally and linguistically diverse background, the sedation provider and their team should:

• access an interpreter if the patient does not speak English as a first language. This service can be by telephone or videoconferencing
• provide accessible translated written communication.

Patients with intellectual disability

Procedural sedation for individuals with intellectual disabilities requires special considerations to ensure safety, comfort and effective management of both the procedure and any behavioural or medical complexities.

The Intellectual Disability Network has a collection of resources that support the delivery of healthcare for people with intellectual disability.

Pre-sedation assessment

A comprehensive telehealth consultation is necessary and often the only option for patients with intellectual disability. This presents a challenge in undertaking a physical assessment, and often means relying on paperwork, history and any further information provided by the carer. Review any previous sedation and anaesthetic history to identify past complications or effective strategies.

Consent and next of kin or guardian involvement

The next of kin or guardian will often need to provide consent on behalf of patients with intellectual disability, therefore they need to be present to consent to any changes to pre-discussed and agreed arrangements.

Involving familiar caregivers is also important for comfort and reassurance. They can provide critical information regarding baseline behaviour, triggers for distress and effective calming strategies.

Environment

Make reasonable adjustments to ensure a quiet, calm and sensory-friendly setting. Where possible, wait times should be minimised to reduce anxiety. Distraction techniques such as music, videos and comfort items should also be considered.

Recovery

Patients with intellectual disability may need to be kept in recovery for longer than other patients. They may become agitated by unfamiliar environments and people. Make adjustments to allow the carer to stay with the patient where possible.

Other considerations

• A behavioural support plan.
• The patient’s preferred communication devices, such as an electronic device or communication boards.

Rural and regional patients

Consider the unique needs of rural and regional patients.

The Rural Health Network works to improve information access and early identification of rural patients, their families and carers.

Before performing a procedure, the risk of the procedure should be considered to ensure that multidisciplinary care and appropriate support can be provided to the patient in the event of a complication or deterioration.

A patient living in a regional or remote area may need help with transport, accommodation and engaging local resources.