Risk stratification

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