Every surgical and procedural society that performs procedures outside of the operating room has developed policies governing the requirements around the use of conscious sedation and moderate sedation in their procedural suites. Society-specific guidelines may also mention the use of general anesthesia; these guidelines make reference to anesthesia-specific guidelines (i.e. American Society of Anesthesiologists in U.S. based practices) when general anesthesia is used within their suites. These also need to be compliant with federal, state, and local statutes [3].

Each individual institution also has established standards for care of their operating room and non-operating room anesthesia locations. These standards are reviewed periodically to reflect changes in equipment/technology, personnel/staffing, and to remove outdated or time-limited information.

Facilities located outside of the hospital environment should have a governing body or medical director who has developed metrics to determine staff competencies in sedation management. Additionally, they can develop risk mitigation strategies and quality improvement activities.

There should be clear guidelines and credentialing requirements for sedation provided by non-anesthesia personnel. An example of such a policy is provided by the American Society of Anesthesiologists [4]. These detailed guidelines stress the importance of developing ongoing systems to check education and training, licensure, practice pattern, and performance improvement [3].

If possible, anesthesia personnel should be involved in the planning and layout phases of any new procedural area that may require sedation and/or general anesthesia services.

Similar to operating rooms, considerations around room design should include (1) room size, (2) room orientation (the procedure table is along the long axis of the room), (3) location of medical gases, (4) location and number of electric and gas outlets, (5) points of entry and egress, and (6) location of the procedure room relative to other facilities (if applicable) [5].

Many non-operating room anesthesia facilities in other departments have procedure tables that are restricted in terms of full mobility. With some procedures, table positioning may preclude easy access to the patient and may require alteration of the anesthetic plan (general anesthesia versus deep sedation for patients in the prone position in small rooms with a significant amount of procedural equipment).

Many procedure rooms require a significant amount of equipment which may be on mobile carts which further decreases the available floor space available in cases of emergency (e.g. for additional staff, a bed to facilitate transfer to perform cardiopulmonary resuscitation or intubation)

Telephone or other two-way communication for the anesthesia provider is necessary in order to mobilize assistance in the event of an emergency, equipment failure, or the need for additional supplies from outside of the sedation suite.

Access to such devices should be readily available to all other providers in the room if the person performing the sedation is unavailable for direct communication.

Access to printed/digital lists of commonly used phone numbers is very useful. Numbers for anesthesia technician assistance, pharmacy, and other medical ancillary personnel (in cases of emergency) should be available.

The standards for anesthesia equipment, supplies, and patient monitoring should match the standards for monitoring in operating rooms conducting similar procedures.

The ASA recommends that wall oxygen, whenever possible, should be used as the primary oxygen supply. Backup systems should include oxygen equivalent to a full E cylinder.

Wall suction should be reliable and accessible; if no wall suction is available, a functioning portable suction device must be present.

If anesthesia machines and monitors are present in the sedation suite, competency on that particular machine should be verified. Troubleshooting checklists should be developed to allow the provider to correct common mechanical issues.

At minimum, the standards that would apply to an operating room anesthesia machine should apply to remote anesthesia machines, including gas analyzers, end-tidal carbon dioxide monitoring, temperature monitoring and reserve oxygen tanks.

Anesthesia machine check and equipment check of monitors, laryngoscopes, airway devices, self-inflating resuscitation bag and monitors is mandatory prior to performing sedation or general anesthesia. If intubation is likely, difficult airway devices should be available.

Equipment noise and room acoustics can make alarm recognition difficult. All monitoring alarms must be readily audible and volume should be adjusted to allowing for recognition over ambient noise. If necessary, two-way mobile devices may be utilized to ensure clear staff-to-staff communication.

Anesthesia supply carts need to have basic anesthesia supplies as well as additional supplies for urgent/emergent situations depending on the availability of ancillary support and the time required to transport those supplies to a remote location.