Accréditation Sans Frontières · ASF Health Standards 9.0
Standard 9 · Critical Care
6 criteria · base standard
Base standard. 6 criteria, of which 3 non-negotiable. Each criterion is numbered 9.Y, with its classification and verification questions.
Criteria
- 9.1 Continuous Physiological Monitoring Appropriate to Acuity (NON-NEGOTIABLE)
- 9.2 Nurse-to-Patient Ratio Matches Acuity (NON-NEGOTIABLE)
- 9.3 Rapid Response and Deterioration Recognition System (NON-NEGOTIABLE)
- 9.4 Sedation and Delirium Management Protocol (CORE)
- 9.5 Family Communication and Presence Policy (CORE)
- 9.6 End-of-Life and Withdrawal of Care Protocol (STANDARD)
9.1 Continuous Physiological Monitoring Appropriate to Acuity
NON-NEGOTIABLE
Every critical care patient is continuously monitored with equipment and alarm parameters individually set to their clinical condition, with alarms responded to, not silenced or ignored due to alarm fatigue.
VERIFICATION QUESTIONS
- Are alarm parameters individually set for each patient's actual condition, not left on generic factory defaults?
Generic defaults can be clinically meaningless for a specific patient's baseline. - Is there a documented response time standard for alarms, verified against actual practice?
Alarm fatigue, where frequent alarms lead to delayed or absent response, is a well-documented critical care risk. - Is monitoring equipment checked and calibrated on a fixed schedule, with a documented process for equipment failure?
Equipment failure in critical care carries immediate, serious risk.
9.2 Nurse-to-Patient Ratio Matches Acuity
NON-NEGOTIABLE
A defined nurse-to-patient ratio appropriate to critical care acuity is maintained at all times, including nights and weekends, with a documented escalation process when staffing falls below the required ratio — not an aspirational standard that quietly erodes under pressure.
VERIFICATION QUESTIONS
- Is the defined ratio maintained, verified against staffing records across different shifts, not just daytime weekday staffing?
Off-hours staffing pressure is a common, specific point where ratios erode. - Is there a documented escalation process when staffing falls below the required ratio?
A defined escalation path, not an informal expectation that staff will manage. - Can the facility show a recorded example of this escalation process being used?
Evidence the process functions in practice, not just exists on paper.
9.3 Rapid Response and Deterioration Recognition System
NON-NEGOTIABLE
A structured early-warning scoring system is used to detect patient deterioration, with a defined rapid response mechanism that staff can activate directly, without needing to escalate through multiple layers before help arrives.
VERIFICATION QUESTIONS
- Is a structured, scored early-warning system used, not informal clinical impression alone?
A structured tool catches early deterioration more reliably than impression alone. - Can any staff member activate the rapid response directly, without needing multiple layers of approval first?
A response requiring lengthy escalation before activation undermines the purpose of a rapid response system. - Is there a documented, verified response time from activation to the responding team's arrival?
An assumed response time, never measured, often proves more optimistic than reality.
9.4 Sedation and Delirium Management Protocol
CORE
A written protocol governs sedation level targets and delirium screening for critical care patients, with sedation minimised to the clinically necessary level and delirium actively screened for on a defined schedule, not assumed absent without active checking.
VERIFICATION QUESTIONS
- Is sedation level targeted to a defined, documented goal, not a default "keep comfortable" approach without a specific target?
Deeper sedation than clinically necessary carries its own documented risks. - Is delirium actively screened for using a validated tool on a defined schedule, not just noticed informally if obvious?
Delirium can be subtle, particularly the hypoactive form, and is frequently missed without active screening. - Does a positive delirium screen trigger a documented clinical response, not just a note in the chart?
Detection without a response provides limited protective value.
9.5 Family Communication and Presence Policy
CORE
A structured process ensures family receives regular, understandable updates on the patient's condition, with a clear, applied family presence policy — not family access or communication left to vary by which staff member happens to be on shift.
VERIFICATION QUESTIONS
- Do families receive regular updates in understandable terms, not sporadic updates that depend on which clinician happens to be available?
Inconsistent communication is a well-documented source of family distress in critical care. - Is the family presence policy applied consistently, not varying significantly by which staff member is on shift?
A policy applied inconsistently functions, in practice, as no policy at all. - Is there a structured process for a family conference at defined clinical points, such as a significant change in prognosis?
A proactive structured conversation, not communication that happens only if family specifically asks.
9.6 End-of-Life and Withdrawal of Care Protocol
STANDARD
A written protocol governs end-of-life decision-making and withdrawal of life-sustaining treatment in critical care, including family involvement, ethics consultation access, and palliative support — not decisions that vary with the individual clinician's approach.
VERIFICATION QUESTIONS
- Does a written protocol guide end-of-life decision-making, not left to vary significantly by individual clinician approach?
Significant unexplained variation in approach between clinicians is a specific, checkable gap. - Is ethics consultation accessible when needed, not a resource that exists on paper but is rarely used?
Verified against actual recent use, not only the existence of an ethics committee. - Is palliative support integrated, not treated as a separate referral that happens only after active treatment has fully stopped?
Palliative support alongside, not only after, active treatment decisions. ————————————————————