Moderate sedation programs: Frequently asked questions

Moderate Sedation Programs: Frequently asked questions

TiER1 Healthcare receives various questions from our clients regarding moderate sedation. Below are the two most frequently asked questions:

Q: Our policy is that privileges must be requested for moderate sedation and the Chief of Anesthesia is ultimately responsible for this. Our ED physicians think they should be excluded from this policy since they are ED. Can you provide us with direction?

A: The American Society of Anesthesiologists (ASA) has a position statement on granting privileges for administration of moderate sedation to practitioners who are not anesthesia professionals. Leading practice would be to consider these guidelines in your privileging process. They have sections describing their recommendations for training, licensure, privileging process, performance criteria, etc.

As you know, it is the responsibility of the Medical Staff to determine which privileges are considered part of the core and which must be requested separately. It would be very unusual to list moderate sedation as a core privilege and state that, by training, a physician group (e.g., ED) was exempt from supplying information about training or requiring any performance data to be collected, limiting the length of time that the privilege was granted, and then require another group who performs the procedure with similar training (e.g., gastroenterologists) to request this as a privilege.

The TJC standards do not specifically cite moderate sedation as a privilege that must be requested. So, it is up to the Medical Staff to define this, and then their recommendations must be approved by the Governing Body (MS.06.01.05, EP. 2). Also, MS.06.01.03 indicates that “all of the criteria used are consistently evaluated for all practitioners holding that privilege.”

Q: When moderate sedation is performed by non-anesthesia providers, are a pre-anesthesia evaluation, intraoperative anesthesia record, and a post-anesthesia evaluation required?

A: According to CMS Tag A-1004, while current practice dictates that the patient receiving moderate sedation be monitored and evaluated before, during, and after the procedure by trained practitioners, a pre-anesthesia evaluation, an intraoperative anesthesia record, and a post-anesthesia evaluation performed by someone qualified to administer anesthesia as specified in §482.52(a) are not required because moderate sedation is not considered to be “anesthesia” and thus is not subject to that requirement under this regulation.

Additional Resources

Download Moderate Sedation Standards and Strategies

Download the Gap Analysis/Risk Assessment Tool

To discuss how TiER1 Healthcare can help build or strengthen your Moderate Sedation Program, call (800) 241-0142 or email

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