The NSW Safe Sedation Project

To the Editor: About 300 000 episodes of procedural sedation occur annually in New South Wales public hospitals. Much of this sedation is supervised by non-anaesthetists.

Complications of procedural sedation are usually related to airway obstruction or depressed ventilation and can be life-threatening. Therefore, clinicians who administer sedation and care for sedated patients should have adequate knowledge and skills to assess, manage and provide rescue to these patients.

The Australian and New Zealand College of Anaesthetists has addressed the issue of procedural sedation since 1984 via policy statement PS09.1 Many specialist groups are cosignatories to PS09; however, its implementation has been incomplete.

Anaesthetists in NSW have long been aware of adverse outcomes from procedural sedation, and of reports from nursing staff who care for sedated patients and who feel poorly trained and unsupported for the tasks required.

The NSW Safe Sedation Project was established to support the safe provision of non-anaesthetist-administered intravenous procedural sedation. The project included development of minimum standards of care, a survey of NSW hospitals to confirm feasibility of the standards and raise awareness of PS09, and development of a toolkit including an audit tool.2

The minimum standards agreed to early in the project were (i) preprocedure: assessment and risk stratification of all patients who receive procedural sedation; (ii) intraprocedure: the constant presence of a dedicated clinician, to monitor and provide airway management for the sedated patient; and (iii) postprocedure: arrangements for monitoring the patient recovering from sedation.

The project team visited over 50 procedural departments in 17 hospitals in a range of metropolitan, regional and rural local health districts (LHDs) between 2012 and 2014. Some units reported underresourcing regarding direct anaesthetist availability, but this was the exception. There was considerable variation in the skill level of nursing staff caring for sedated patients (corresponding with scenario 1 in appendix 3 of PS09). This has also been observed by other authors.3

As project leaders, we recommend that consistent, high-quality education and training be developed and implemented for all clinical staff who regularly manage sedated patients. This training should be aligned with competency-based assessment.

We also recommend the development of hospital- or LHD-wide systems of governance and support for provision of sedation by non-anaesthetists.

To maximise the efficient use of highly skilled clinicians, hospitals and LHDs should consider developing processes that enable the triage of higher-risk patients to anaesthetists for sedation, and support appropriately trained and skilled non-anaesthetist sedation providers for lower-risk patients.

The Safe Sedation Project toolkit is available via the NSW Agency for Clinical Innovation website.2