Chapter 7: Guidelines for the Provision of Anaesthesia Services in the Non-theatre Environment 2024

Published: 31/01/2023


There are increasing numbers of diagnostic and therapeutic procedures performed outside the main theatre environment, in both elective and emergency situations. These procedures may require anaesthetic involvement through haemodynamic monitoring during the procedure, sedation, regional anaesthesia or general anaesthesia. The challenge for anaesthesia is to develop a framework that supports and regulates the safe delivery of care.

Commercial and NHS healthcare providers are expanding non-theatre environments to deliver surgical and diagnostic procedures. This framework guidance should be applied to all non-theatre services that require anaesthetic interventions.

The complexity and challenges of providing anaesthesia care in the non-theatre environment should be acknowledged through appropriate regulation of healthcare providers and training and certification of anaesthesia providers. All clinical personnel assisting with anaesthesia should be certified resuscitation providers.

Facilities delivering anaesthesia and sedation by anaesthetic providers should develop a culture of safety that reflects Guidelines for the Provision of Anaesthetic Services (GPAS) guidelines. Patients expect uniformly high standards of service provision wherever the service is provided and whoever is the provider.

The development of deep sedation techniques and general anaesthesia with total intravenous anaesthesia (TIVA)/target-controlled infusion techniques may remove the requirement for complex gas delivery systems and anaesthetic machines. The safe delivery of anaesthesia through preoperative assessment, case selection, anaesthesia delivery, recovery and postoperative care should not be compromised because of cost pressures.

The physical environment can be challenging for the safe provision of anaesthesia when compared with the main theatre environment. The anaesthesia providers should develop safe practice guidelines that consider the assessment, induction, recovery and discharge of patients. In addition, procedure-specific risks such as radiation exposure and infection control should be considered. Compliance with the surgical safety checklist is obligatory.1 Complication management should be written into patient pathways with consideration of access to other medical, surgical, and critical care services.

1. Staffing requirements


A clinical lead(s) (see Glossary) for anaesthesia in the non-theatre environment should be appointed with adequate time provided within their job plan to develop the service, train staff, and ensure that safety standards are upheld.2,5,6 The anaesthesia clinical lead for the non-theatre environment should create local consensus guidelines for the staffing of each non-theatre area where anaesthesia is delivered.

C Strong

An escalation policy should be in place and should be understood by all medical, healthcare professional and managerial staff. This should include the names and method of contact, which should be prominently displayed in appropriate areas. Internal hospital telephone switchboards should have ready access to rotas and methods of contacts.7

C Strong

The non-theatre environment involves multiple clinical teams working together. There should be an anaesthesia clinical lead to coordinate, collaborate, and communicate between clinical teams and to offer effective, explicit leadership.5

C Strong

A dedicated, appropriately trained anaesthetic assistant, who is familiar with that specific environment, should be available in all non-theatre environments where anaesthesia or deep sedation is undertaken by an anaesthetist.8,9

C Strong

Patients recovering from anaesthesia or all depths of sedation including mild sedation (see Glossary) in a non-theatre environment should receive the same standard of care as that required in an operating theatre.10,11

C Strong

The requirements for non-theatre anaesthesia services out of hours should be locally agreed and sufficient staffing should be in place to deliver all aspects of the emergency workload without compromising patient safety.12

C Strong

If a radiology department provides an emergency interventional service for which anaesthesia services may be required, plans for staffing this anaesthetic service should be made, particularly outside normal working hours. Clear referral pathways for anaesthetic support for interventional radiology should be provided for all hours the service is offered.13,14,15,16

C Strong

Anaesthesia for non-theatre environment should be delivered by a competent individual with appropriate supervision; the level of supervision should reflect the severity of the case and the seniority of the individual in accordance with the RCoA's Guidance on Supervision Arrangements for Anaesthetists.17

C Strong

Anaesthetists in training should be given the appropriate level of responsibility according to their competence and level of training, to gain the experience of non-theatre environment and to enable them to function as a consultant later in their career. Anaesthetists in training must be appropriately supervised at all times; rotas and staffing arrangements should be in place to facilitate this training.18

M Strong

2. Facilities, equipment, medication and services



Access to lifts for easy trolley transfer should be available.

GPP Strong

Procedure rooms should be large enough to accommodate equipment and personnel, with enough space to move about safely and to enable easy access to the patient at all times.19

B Strong

Environments in which patients receive anaesthesia or sedation should have full facilities for resuscitation available, including a defibrillator, suction, oxygen, airway devices, an escalating plan of airway intervention equipment, including equipment required to manage a difficult airway and a means of providing ventilation.20

C Strong

The anaesthetist should consider all environmental factors when planning administration of anaesthesia or sedation.21

B Strong

When rooms are darkened, hindering direct observation of the patient, an alternative light source should be available to facilitate patient observation and documentation.21

B Strong

Transfer of a patient from the procedure room to other areas within the institution should be possible to arrange if necessary.

GPP Strong

A recovery area or equivalent should be available for each patient at the end of the procedure.19

B Strong

A telephone and facilities to allow access to online information, such as electronic patient records, local guidelines and clinical decision aids, should be available.21

B Moderate



Equipment for the minimum standards of monitoring should be available at all sites where patients receive anaesthesia or sedation.22 For patients receiving conscious sedation, this should include pulse oximetry.

C Strong

Continuous waveform capnography should be available for all patients undergoing general anaesthesia and moderate or deep sedation.22,23

C Strong

The anaesthetist should ensure that an adequate supply of oxygen is available before starting any procedure. Many of the sites where anaesthesia is provided outside the main operating theatres do not have piped oxygen; if anaesthesia is provided frequently in such a location, the use of the location should be reviewed, or piped oxygen provided. The organisational culture should enable anaesthetists to raise concerns if safety and monitoring standards are compromised.21

B Strong

Where piped oxygen is used, back-up cylinders should always be available and should be appropriately stored.

GPP Strong

All anaesthetic equipment should be standardised (where possible) in all areas providing anaesthetic services, including equipment for resuscitation and life support with the exception of any equipment that needs to be magnetic-resonance (MR) safe. All anaesthetic equipment should be subjected to a standardised programme of maintenance.21

B Moderate

All staff should be provided with opportunities to familiarise themselves with all equipment by attending formal training sessions.21 Training sessions should be documented accordingly.

B Strong

Equipment standards where anaesthesia is planned, including with controlled ventilation, should replicate the facilities available in the main theatre suites and should be commensurate with local hospital anaesthetic facilities.21,24

C Strong

All anaesthetic equipment should be checked prior to use in accordance with the Association of Anaesthetists published guidelines.25 Anaesthetic machine checks should be recorded in a logbook and on the anaesthetic chart.

C Strong

All procedures should be compliant with National Safety Standards for Invasive Procedures (NatSSIPs) and the Safe Surgery Checklist.26,27 An appropriate ‘pre-list check’ of the anaesthesia systems, facilities, equipment, supplies and resuscitation equipment should be performed prior to the start of each list.21

C Strong

Appropriate equipment should be available to monitor a patient’s temperature, to minimise heat loss and to provide active patient warming.24

C Strong

All patient trolleys should be capable of being tipped into the head-down position and should be easily transferrable to the rest of the hospital.24 The exception to this is the MR safe trolleys.

C Strong



A standardised list of anaesthesia medications should be available wherever anaesthesia or sedation is undertaken. A full range of emergency medications, including specific reversal agents such as naloxone, sugammadex and flumazenil, should be available.28

B Strong

In remote locations where anaesthesia is undertaken, medications to treat rare situations, such as dantrolene for malignant hyperthermia or intralipid for local anaesthetic toxicity, should be immediately (see Glossary) available and located in a designated area.28

B Strong

There must be a system for ordering, storage, recording and auditing of controlled drugs in all areas where they are used, in accordance with legislation.24,29,30,31,32

M Mandatory

Robust systems should be in place to ensure reliable medicines management, including storage facilities, stock review, supply, expiry checks and access to appropriately trained pharmacy staff to manage any drug shortages.24,33

C Strong

All local anaesthetic solutions should be stored separately from intravenous infusion solutions, to reduce the risk of accidental intravenous administration of such drugs.24,34

C Strong

Drug labels should be used to identify syringes and infusions that contain medications.24,35 A robust system of communication between the anaesthetists, nursing staff and proceduralists, including confirmation of medications, should be in place to avoid miscommunication and miscalculation errors.28

C Strong

Local guidelines should consider mitigating the risk of drug overdose for drugs that are available in different strengths. Stocking medications in only one strength (e.g., ketamine and midazolam) can decrease the incidence of medication errors.

GPP Aspirational

Prefilled syringes supplied by the pharmacy should be considered, especially in areas where anaesthesia is delivered in an emergency.36



Patients should be appropriately monitored by trained staff during their recovery from anaesthesia or sedation.24

C Strong

The care of the patient should remain the responsibility of the anaesthetist up to discharge for ambulatory procedures or ward transfer for inpatient procedures.

GPP Strong

3. Areas of special requirement


Children presenting for anaesthesia outside the operating room may present challenges relating to the procedure, the environment, or physical, physiological and psychological challenges. Children often require repeat treatments or investigations. Minor procedures and diagnostic tests may be performed with sedation techniques. In addition, anaesthesia may be required for more invasive procedures in children.37,38

Detailed recommendations for children’s services are comprehensively described in GPAS Chapter 10: Guidelines for the Provision of Paediatric Services.39


Children should always be managed in accordance with RCoA and Association of Paediatric Anaesthetists of Great Britain and Ireland recommendations.

C Strong

Each facility should develop written policies, designating the types of paediatric operative diagnostic and therapeutic procedures requiring anaesthesia.

GPP Strong

The paediatric anaesthetist should consider the patient’s age and physical capacity, the complexity of the procedure and the status of the surgical facility before administering anaesthesia. Children with learning and/or communication difficulties requiring sedation or anaesthesia should be cared for as per the recommendations of GPAS Chapter 10: Guidelines for the Provision of Paediatric Services.39

GPP Strong

Irrespective of the site of care delivery (theatre or non-theatre), children should receive the same standard of anaesthetic care or sedation as applied to procedures performed in theatre.40

C Strong

Equipment available in remote sites should replicate equipment available in the main paediatric facility.

GPP Strong

Guidance for paediatric sedation should be developed for the local context by a multidisciplinary team.

GPP Strong

Paediatric sedation should be managed in accordance with recognised national guidelines.41,42

C Strong

Patients with additional needs, including learning disabilities and neurodiversity


Where necessary, premedication or sedation should be considered for patients with additional needs, including those with extreme anxiety.43

C Moderate

Where possible, reasonable adjustments to processes and environments should be made to reduce anxiety and avoid the need for elaborate premedication of patients. Such adjustments may include admission directly to the procedure room, wearing outdoor clothes, and/or not performing observations.43,44

C Moderate

All patients with complex needs should have a suitable preoperative assessment and multidisciplinary planning and an anaesthetist should be involved in the best-interest discussions regarding individual risk.43,45 Learning disability liaison teams or equivalent should be involved early in care planning.

C Strong

Consideration should be given to providing additional flexibility in the timing of lists to allow adequate time for patients with learning disabilities.43,45

C Moderate

Where it is offered, policies should be in place for home sedation for patients who will not leave their homes, in conjunction with the ambulance service. This should involve a risk assessment, a detailed plan and emergency contingencies.44,45,46

C Moderate

Policies should be in place for in-car or entrance-hall sedation for patients who will leave home but who have difficulties entering the hospital environment.45

C Moderate

Policies should be in place for the safe administration of anxiolytic premedication within the admissions area or anaesthetic room.44,45,46

C Strong

Any preprocedure sedation that occurs outside a normal clinical environment should have all the anaesthetic equipment that is required for monitoring and airway support plus a trained assistant available. There should be formal training in the pathways used.

GPP Strong

Bespoke plans should be clearly communicated and documented with contingencies and escalation.

GPP Strong

If a patient with additional needs requires multiple procedures to be conducted during a single anaesthetic, appropriate logistical planning should be considered, including arrangements for safe transfer to other non-theatre sites where applicable.

GPP Moderate

Safe recovery of patients with learning disabilities should be planned in advance. Patients should ideally be recovered in an area with lower levels of noise and lighting and should have a familiar presence, such as their carer, present.43

C Moderate

Appropriate exposure should be given to anaesthetists during their training to develop skills in reasonable adjustments and anxiolysis. Allied professionals specialising in this area should also be given training.44,45

C Moderate

The emergency department

Patients requiring anaesthesia in the ED are frequently critically ill or injured. Their physiological derangement and sensitivity to anaesthetic agents, coupled with the potential for increased difficulty in tracheal intubation, requires the presence of an anaesthetist competent to manage these challenges in a timely and effective manner.47


In a designated major trauma centre, the receiving trauma team should include an anaesthetist with appropriate airway and damage control resuscitation competencies to manage trauma patients.48,49

C Strong

The safe management of unstable patients depends on close liaison between emergency physicians, anaesthetists and intensivists.50,51 Local collaboration and leadership through committee structure or working groups should ensure the following:

  • clear guidelines are easily accessible to all staff regarding fixed contact points for anaesthetic support, channels of escalation, equipment availability, medication use and periprocedural care.52 Major trauma and neuroscience centres should consider producing generic guidance on specific clinical presentations to support rotating clinicians with limited experience
  • all anaesthetic staff providing support to the ED within the context of their job plan should be offered a tour of the ED as part of their induction
  • ED support staff should be regularly trained to assist with advanced airway interventions such as tracheal intubation
  • advanced airway interventions should be clearly recorded in patient notes in a structured format that facilitates review, debrief and continuous quality improvement work
  • audit and discussion of complications should be undertaken regularly by the multidisciplinary team.
C Strong

Emergency airway management in the ED should follow the recommendations of the collaborative working framework of the Royal College of Emergency Medicine and the Faculty of Intensive Care Medicine.53,54

C Strong

The use of an emergency induction checklist is recommended. Airway and resuscitation equipment should be organised as per the equipment governance recommendations of the collaborative framework of the Royal College of Emergency Medicine and the Faculty of Intensive Care Medicine.54

C Strong

Local and national guidelines should be adhered to for patients requiring inter-hospital transfer to the regional trauma centre.55 Equipment for transfer should be organised in accordance with the recommendations of the collaborative framework of the Royal College of Emergency Medicine and the Faculty of Intensive Care Medicine.54

C Strong

Transfer of patients within the hospital to the intensive care unit, radiology department or the operating theatre is not without risk and will require the use of a tipping transfer trolley, oxygen cylinders, suction, a transport ventilator, infusion pumps, monitor with adequate battery life, and a portable defibrillator, if appropriate. Local guidelines, together with use of a formal intrahospital transfer form, should be considered to mitigate procedure-specific issues.

GPP Strong

Procedural sedation and analgesia in the ED should follow the recommendations from the RCoA and the Royal College of Emergency Medicine.36 Medications and medication safety systems in the ED should align with the recommendations of the collaborative framework of the Royal College of Emergency Medicine and the Faculty of Intensive Care Medicine.54


C Strong

The radiology department

Patients requiring general anaesthesia in the radiology department are of all ages and comorbid conditions, requiring everything from planned elective care to emergency care for life-threatening conditions. Increasingly complex, lengthy procedures are performed in the radiology department at all times, and this represents a more challenging environment in which to provide anaesthesia compared with an operating theatre.5


Exposure to ionising radiation should be kept to a minimum using screens and personal protective equipment such as lead gowns and thyroid shields. Remote secondary monitors in screened viewing areas should be provided and staff should remain as distant from the imaging source as possible if they remain in the x-ray environment.56,57

C Strong

Anaesthetists who work regularly within the radiology department should be issued with personal dosimeters by their employer to monitor their radiation exposure and to ensure that levels remain within statutory dose limits.58

C Strong

The anaesthetist accompanying transferred patients to the radiology department should be suitably skilled and experienced to manage all eventualities in an isolated environment and should be accompanied by a dedicated trained assistant.7

C Strong

As not all radiology tables tilt into a head-down position, a tipping trolley should be available for patients who require general anaesthesia.

GPP Strong

Interventional radiology

Recommendations on the provision of mechanical thrombectomy services can be found in Chapter 14: Guidelines for the Provision of Neuroanaesthesia Services.


The provision of anaesthesia services should be considered when designing interventional radiology services and there should be agreement about the level of provision and protocols to request anaesthetic support for both elective and emergency cases.

GPP Strong

Procedure-specific agents, such as those required to manipulate coagulation, intracranial pressure or arterial blood pressure, should be available.60

C Strong

Interventional vascular radiology may involve treating unstable patients with severe haemorrhage. Such patients may include those with significant gastrointestinal bleeding or patients with postpartum haemorrhage.61,62,63 Equipment to deal with these situations should be immediately available. This includes a variety of intravascular catheters, rapid infusion devices, blood and fluid warming devices, and patient warming devices.

C Strong

The local protocol for major haemorrhage should be available and should be rehearsed periodically as a team by formal simulation or other training sessions.

GPP Strong

Magnetic resonance imaging


National guidelines for the management of patients in the MRI suite should be available and followed.64,65,66,67

C Strong

There should be locally agreed protocols and pathways for the provision of anaesthetic services in MRI both in and out of hours.

GPP Strong

Anaesthetic equipment that is used in the MRI room should be MR safe or conditional.5,67

C Strong

Remote monitoring of the patient with a secondary screen in the control room should be available to allow the anaesthetic team to monitor the patient from outside of the magnetic field.

GPP Strong

Particular consideration should be given to the problems of using infusion pumps. All non-essential pumps and equipment should be removed from the patient before entering the magnetic field. MR safe or conditional infusion pumps or the use of a protective MR capsule for standard pumps should be available wherever anaesthesia is provided regularly. Infusions with extra-long giving sets can be used when MRI-specific pumps are not available.

GPP Strong

All staff involved with transferring a patient to the MRI scanner should understand the unique problems caused by monitoring and anaesthetic equipment in this environment. It is not acceptable for inexperienced staff unfamiliar with the MR environment to escort or manage a patient in this environment, particularly out of hours.65,66,68

C Strong

The patient and all staff should have an MRI safety and exclusion questionnaire completed before entering the magnetic field.

GPP Strong

In the event of an adverse incident in the MRI scanning room, the patient should be removed from the scanning room without delay and immediate access to an anaesthetic preparation room or resuscitation area is required.5

C Strong

Anaesthesia for electroconvulsive therapy


Anaesthesia for ECT is frequently performed in remote locations. Ideally, a consultant or an autonomously practising anaesthetist (see Glossary) should provide general anaesthesia. Appropriately trained recovery and operating department staff should be provided, and the guidance provided for anaesthetic provision in remote sites should be followed.69

C Strong

The ECT clinic should adhere to the ECT Accreditation Service (ECTAS) or Scottish ECT Accreditation Network (SEAN) standards for administration of ECT and have been assessed and accredited by ECTAS or SEAN.69

C Strong

There should be a clinical lead (see Glossary) for ECT who is responsible for provision of the service in each anaesthetic department. The named consultant should be responsible for determining the optimal location for provision of anaesthesia for patients of American Society of Anesthesiologists classification III or above. Contingency plans for transfer to an acute care facility should also be in place.69,70

C Strong

The ECT clinical lead should streamline the preassessment and consent processes for all ECT patients by setting up a collaborative system with ECT clinics and experienced anaesthetists. The mental capacity issues that affect informed consent should be acknowledged.

GPP Strong

Anaesthetists should have specialised knowledge of the effect of concurrent medications, anaesthetic agents, anaesthetic techniques and equipment on the conduct and efficacy of ECT, as well as the specific anaesthetic contraindications.70,71

C Strong

Standards specific to ECT clinics should be available, including a minimum of four rooms: a waiting room, treatment room, recovery area and post-ECT waiting area.69 The clinic should have a reliable source of oxygen supplied either by pipeline or cylinder with a reserve supply immediately available.

C Strong

Recommendations for standards of monitoring during anaesthesia and recovery are stipulated by the Association of Anaesthetists and should be adhered to for all patients undergoing ECT.22

C Strong

Anaesthesia for direct current cardioversion

The disturbance of physiological rhythm, the reduction in cardiac performance and the risk of embolic phenomena all place patients requiring DC cardioversion at risk of serious complications when undergoing both anaesthesia and DC cardioversion.2

Detailed recommendations for cardiac procedures can be found in Guidance on the Provision of Anaesthesia Services for Cardiac Procedures.


External pacing equipment should be immediately available before beginning DC cardioversion.2

C Strong

Facilities to check recent serum electrolytes, in particular potassium and preferably magnesium, as well as the patient’s anticoagulation status and a recent ECG should be available before beginning a DC cardioversion. A preprocedural echocardiogram is likely to provide useful information such as the presence of thrombus within the cardiac chambers.72


The anaesthetist should not be responsible for performing the cardioversion; an appropriately trained physician, cardiologist or supervised nurse specialist is responsible for this role.50

C Strong

Anaesthesia for radiotherapy


Anaesthesia may be required for radiotherapy, to facilitate patient positioning and to alleviate pain. Owing to the unique nature of the procedures involved in radiotherapy, the remoteness of the location and the lack of direct access to the patient, only appropriately experienced anaesthetists familiar with the therapy should embark on anaesthesia for these patients.73

C Strong

Anaesthetists should be familiar with the specific needs of patients with cancer, including the following:

  • the adverse effects of high concentrations of oxygen in the presence of some antineoplastic agents, for example bleomycin, and should adjust their technique accordingly.[i],[ii] Recent evidence confirms the association between unnecessarily high intraoperative fraction of inspired oxygen and increased risk of major respiratory complications and 30-day mortality. Inspired oxygen levels may require adjustment to maintain an acceptable level of tissue oxygenation75
  • the interference of nitrous oxide with vitamin B12 and folate metabolism.76
C Strong

Patients with tumours of the lower body may be amenable to regional anaesthesia. Equipment and facilities to instigate, monitor and manage regional blockade should be available.74

C Moderate

General anaesthesia and sedation for dental procedures


General anaesthesia for dentistry should be administered only by anaesthetists in a hospital setting as defined by the Department of Health report reviewing general anaesthesia and conscious sedation in primary dental care.77

C Strong

Patients undergoing sedation or general anaesthesia by an anaesthetist should have appropriate preoperative assessment with appropriate risk stratification.

GPP Strong

Gastrointestinal procedures


Standards of service provided to patients receiving endoscopic procedures supported by anaesthetic staff in the non-theatre environment should be comparable to other anaesthetic services.

GPP Strong

Anaesthetic staff providing care in the endoscopy suite should be familiar with the facility, equipment and techniques.

GPP Strong

Preoperative assessment of elective patients receiving anaesthesia or sedation from anaesthetic personnel should be of a comparable standard to other anaesthesia services.

GPP Strong

The risks of serious adverse events during emergency endoscopy are elevated when compared with elective procedures. Local protocols should include specific guidelines for emergency endoscopy and the involvement of the anaesthetic team.

GPP Strong

A patient-centred safety checklist should be used for patients receiving endoscopy under sedation.78

C Strong

Monitoring of patients receiving anaesthesia or sedation for endoscopy provided by anaesthetic personnel should be comparable to other anaesthesia services.

GPP Strong

High-flow nasal oxygen therapy should be available for anaesthesia-delivered sedation or general anaesthesia for endoscopic procedures.

GPP Strong

The post-anaesthetic recovery facilities when provided for patients following anaesthesia delivered sedation or anaesthesia should be comparable to those provided in theatre environments. The provision of a handover checklist can improve the transfer of care in the recovery setting conveying pertinent clinical and procedural information.

GPP Strong

Critical incidents should be reviewed at regular intervals and should be analysed for trends and learning for the procedural team and wider hospital. This can involve a review of all hospital-related procedural sedation critical events.

GPP Strong

4. Organisation and administration


Patient safety is, as always, of paramount importance. Particular attention should be paid to teamwork, communication, the use of checklists and procedure brief when working in less familiar environments. At the team briefing, an explicit plan should be agreed for requesting help if required, recognising the risk of, and preparing adequately for, high blood loss, and life-threatening loss of the airway or respiratory function.84

C Strong

Many patients undergoing elective procedures outside the operating theatre can be managed as day cases and should be assessed accordingly in conjunction with local guidelines. All patients should undergo an appropriate risk assessment and level of preoperative assessment in line with the GPAS recommendations in Guidelines for the Provision of Anaesthesia Services for the Perioperative Care of Elective and Urgent Care Patients.24,85

C Strong

Hospitals should have a system for multidisciplinary involvement in reporting and regular audit of critical incidents and near misses. A risk register should be maintained for all remote locations in the hospital.

GPP Strong

Environmental hazards such as radiation exposure, MR fields and lack of a scavenging system should be considered by staff before the start of each list. Volatile agent scavenging canisters, air-oxygen mixtures and avoidance of nitrous oxide can mitigate environmental risks. Consider TIVA where adequate scavenging cannot be achieved. Personnel who are pregnant may be particularly at risk in these environments and should follow local occupational health policy.86

C Moderate

In remote offsite locations, such as psychiatric hospitals where anaesthesia is provided for ECT, advanced plans should be made to manage patient transfer if required. If there is any concern about the safety of the procedure being undertaken by any staff members at a remote location (e.g. ECT in a psychiatric hospital), arrangements should be made to perform the procedure in an operating theatre environment.

GPP Strong

Documentation to the standard used in the operating theatre should be kept for all patients and this should include the grade and specialty of the doctor performing and supervising the anaesthetic, together with the name of the supervising consultant designated to provide direct or indirect advice.24 Access to the electronic patient record and medical notes should be available at all remote sites.

C Strong

The department of anaesthesia should be involved in the design and planning of any service requiring the provision of anaesthesia or deep sedation. A regular review of the remote location performance, critical incidents and further improvements should be held.87

C Strong

Patients meeting discharge criteria following anaesthesia or sedation should be discharged into the care of a responsible third party. Verbal and written instructions for post-procedural care should be provided if a procedure has been performed outlined in Chapter 6: Guidelines for the Provision of Anaesthesia Services for Day Surgery.88

C Strong


The RCoA recognises the definitions of minimal, moderate and deep sedation as outlined in the Academy of Medical Royal Colleges guidance on safe sedation.2,3 Deep sedation equates to general anaesthesia and the recommendations outlined in Chapter 2: Guidelines for the Provision of Anaesthesia Services for the Perioperative Care of Elective and Urgent Care Patients should be followed.

The RCoA does not provide recommendations for sedation provided by non-anaesthetists and they are encouraged to follow the guidance of their own Colleges and the Academy of Medical Royal Colleges.2,3,24


A named anaesthetist should be responsible for liaising with consultants in other departments who have responsibility for sedation, to establish local guidelines and training for the provision of safe sedation by non-anaesthetists.2,3,89

C Strong

All institutions where sedation is practised should have a sedation committee. This committee should include key clinical teams using procedural sedation and there should be a nominated clinical lead for sedation. In most institutions, the sedation committee should include an anaesthetist, at least in an advisory capacity.

GPP Strong

Each facility should develop written policies, designating the types of operative, diagnostic and therapeutic procedures requiring anaesthesia or sedation.

GPP Strong

Guidelines for the management of rare emergencies should be prominently displayed at all sites where sedation is administered.

GPP Strong

Mis-selection of high-strength midazolam during conscious sedation is defined as a ‘never event’ by the Department of Health.90 Hospitals should report these incidents and any other incidents involving over-sedation to the National Reporting and Learning System.

C Strong

All patients undergoing procedural sedation should have oxygen saturation monitoring from the administration of sedation to discharge from recovery. Supplemental oxygen should be available and used, as necessary.54

C Strong

Pulse oximetry, ECG, automated non-invasive blood pressure monitoring and wherever there is loss of verbal contact, continuous waveform capnography, should be considered and continued into the recovery period.22

C Strong

As a result of the continuum of depth of anaesthesia, individuals administering moderate sedation should be able to rescue patients who enter deep sedation. Those administering deep sedation should be adequately trained to rescue patients who enter a state of general anaesthesia. This requires skilled anaesthetic assistance and equipment and involves the potential for airway intervention and support of both ventilation and cardiovascular function.91

C Strong

Sedation practitioners should maintain a logbook of cases performed and adverse incidents reported.

GPP Strong

5. Financial considerations

Part of the methodology used in this Chapter in making recommendations is a consideration of the financial impact for each of the recommendations. Very few of the literature sources from which these recommendations have been drawn have included financial analysis.

The vast majority of the recommendations are not new recommendations but they are a synthesis of existing recommendations. The current compliance rates with many of the recommendations are unknown, so it is not possible to calculate the financial impact of the recommendations in this Chapter being widely accepted into future practice. It is impossible to make an overall assessment of the financial impact of these recommendations with the currently available information.

6. Research, audit and quality improvement

Non-theatre anaesthetic practice should adhere to the same standards of safety, audit and quality improvement as operating room practice, especially as morbidity and mortality rates can be higher in the non-theatre environment.19 Clinical governance procedures should follow the guidelines of Guidelines for the Provision of Anaesthesia Services: The Good Department.


There should be local multidisciplinary audit programmes analysing systems, outcomes and patient experience relating to anaesthesia and sedation in the non-theatre environment.

GPP Strong

Audit programmes should be under regular review by a clinical lead and those relating to sedation should be coordinated by a hospital sedation committee.2,3

C Strong

Regular feedback should be provided to anaesthetic staff and they should be encouraged to participate in quality improvement activities.

GPP Moderate

Compliance with agreed guidelines should be audited, such as World Health Organization surgical safety checklist compliance, equipment and monitoring standards, and anaesthetic record keeping.1,92

C Moderate

Anaesthesia departments should participate in relevant audit and research activities of national bodies such as the Health Services Research Centre and National Confidential Enquiry into Patient Outcome and Death.92

C Moderate

All episodes of anaesthesia in the non-theatre environment should be captured in a structured record within clinical notes.

GPP Strong

Regular multidisciplinary team review should be encouraged, with appropriate service improvement initiatives and shared learning.

GPP Moderate

Contribution to airway registries, such as the Difficult Airway Society Database and Emergency Medicine Airway Registry, should be encouraged.

GPP Moderate

7. Implementation support

The Anaesthesia Clinical Services Accreditation (ACSA) scheme, run by the RCoA, provides a set of standards based on the recommendations contained in the GPAS chapters. As part of the scheme, departments of anaesthesia  self-assess against the standards and undertake quality improvement projects to close the gap. Support is provided by the RCoA in the form of the good practice library, which shares documents and ideas from other departments on how to meet the standards. Further advice can be obtained from the ACSA team and department’s assigned College guide.

The ACSA standards are regularly reviewed on at least a three yearly basis to ensure that they reflect current GPAS recommendations and good practice. This feedback process works both ways and the ACSA scheme regularly provides CDGs with comments on the GPAS recommendations, based on departments’ experience of implementing the recommendations.

Further information about the ACSA scheme can be found here:

8. Patient information

The Royal College of Anaesthetists has developed a range of Trusted Information Creator Kitemark-accredited patient information resources that can be accessed from the RCoA website, including information on sedation, resources for children and young people and accessible resources. Our main leaflets are now translated into more than 20 languages, including Welsh.

Patients with learning and other difficulties may need special assistance and consideration, with specific strategies put in place to aid communication. Further recommendations for patients with additional needs are found in section 3 of this document.


All patients (and relatives where appropriate and relevant) should be fully informed about the planned procedure and should be encouraged to be active participants in decisions about their care. Recommendations about the provision of information and consent processes outlined in Guidelines for the Provision of Anaesthesia Services for the Perioperative Care of Elective and Urgent Care Patients should be followed.24

C Strong

Although separate written consent for anaesthesia is not mandatory in the UK, there should be a written record of all discussions with patients undergoing sedation or anaesthesia about methods of induction, associated risks and side effects.2,67

C Strong

In situations where rolling consent is used (e.g. radiotherapy treatment), appropriate documentation should be kept as part of the patient record, including dates for review of consent. This should be included in the trust’s policy on consent.

GPP Aspirational

Information regarding planned procedures outside the operating theatre and the requirement for sedation or anaesthesia should be given to the patient in advance of their admission. Details on fasting times and medications to continue or omit should be included. The patient needs to be aware that they require a competent adult to escort them home after receiving sedation or alternatively require an inpatient hospital stay.2

GPP Strong

Information given to patients should include what to expect in the anaesthetic room and the treatment room.93

C Strong

Preoperative assessment and information should be given as per surgical procedures.44

C Strong

Patients from non-English speaking groups may require interpreters. Hospitals should have arrangements in place to provide language support, including interpretation and translation (including sign language and Braille). This information should comply with the NHS England Accessible Information Standard.94

C Strong

The relevant mental capacity legislation must be complied with.95,96,97 Staff should have regular training in its application and have defined access to patient advocates. This is a rapidly changing area and clinicians should have access to expert advice.

M Mandatory

Hospitals should have local policies in place for the identification, support and safeguarding of vulnerable adults.98

C Strong

Areas for future development

  • A more detailed national audit of critical incidents associated with anaesthesia in the non-theatre environment should be considered.
  • Paediatric surgical techniques and practices are evolving, and it is likely that the demand for out of theatre surgical procedures and radiological investigations will increase.
  • The use of open MRI scanners for claustrophobic patients as an alternative to anaesthesia or sedation is available in some hospitals. Current evidence shows that the image quality is not yet comparable to that of enclosed MRI scanners. However, with further research and improvements this may become a consideration for the future.


Autonomously practising anaesthetist - a consultant, or an associate specialist, specialist doctor and speciality doctor (SAS) doctor who can function autonomously to a level of defined competencies, as agreed within local clinical governance frameworks. 

Clinical lead – doctors undertaking lead roles should be autonomously practising doctors who have competence, experience and communication skills in the specialist area equivalent to consultant colleagues. They should usually have experience in teaching and education relevant to the role and they should participate in quality improvement and continued professional development activities. Individuals should be fully supported by their clinical director and should be provided with adequate time and resources to allow them to undertake the lead role effectively.

Deep sedation – describes a state where the patient cannot easily be roused but responds purposefully to repeated or painful stimulation. It may be accompanied by clinically significant ventilatory depression. The patient may require assistance maintaining a patent airway and positive pressure ventilation.

Immediately – unless otherwise defined, ‘immediately’ means within five minutes.

Minimal sedation – is a drug-induced state during which the patient responds normally to verbal commands. Cognitive function and physical coordination may be impaired but airway reflexes, ventilatory and cardiovascular functions are unaffected.

Magnetic-resonance compatible – equipment that is designated as MR compatible is MR safe, functions normally in the MR environment and does not interfere with the correct operation of the MRI equipment provided that instructions concerning its proper use are correctly followed.

Moderate sedation/mild sedation – a state where a purposeful response to verbal commands, either alone (conscious sedation) or accompanied by light tactile stimulation, is maintained.


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