PTR-SOP-002: Care level classification and crew matching

Standards › Standard S6 › Standard operating procedures (SOPs)

Standard operating procedure (SOP) · PTR-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee

Supports: System S6 (Patient transfers and referrals), criterion S6.6, S6.7, S6.11, S6.12

At a glance

Classify each transfer by the required care level from the assessment.
Match the vehicle, crew and equipment to that level before departure.
Apply the written minimum crew for each transfer type.
Check the crew’s skills match the acuity of each patient carried.
Stop and get help straight away if: a transfer leaves with a vehicle, crew or equipment below the level the patient needs.

1. Purpose

To send each patient with the right vehicle, crew and equipment for their condition (S6.6, S6.7, S6.11, S6.12).

2. Scope

Applies to	Clinical and support staff in the hospital
Locations	All wards, clinics and departments of the facility
When	Whenever the activity described is carried out
Does not apply to	Activities covered by another document listed in section 15

3. Definitions

Term	Meaning
Clinical lead	The doctor or nurse in charge of the area at the time

4. Background

Transport with too few people on board fails when one person is busy with the patient and the vehicle needs attention. A written minimum crew makes the safe number a fixed rule, not a judgement on the day.

5. Responsibilities

Role	Responsibility	Competence
Dispatch lead	Classifies and matches before departure	Trained dispatcher
Crew lead	Confirms the crew can meet the level	Trained crew

6. Materials and equipment

Item	Requirement	Condition
Records and forms named in this document	Current version	Checked before use

7. Safety

Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.

8. Before you start

Confirm the forms and equipment named in this document are available and current.

9. Procedure

Step 1. Classify.

Use the assessment to set the care level for the transfer (PTR-FRM-003).

Key point: The level comes from the patient, not the booking.

Step 2. Match.

Match vehicle, crew complement and equipment to the level.
If no match exists, do not depart; arrange a higher level.

Key point: No match, no departure.

Step 3. Check skills.

Confirm each crew member’s scope of practice covers the acuity they will carry.

Key point: Scope limits are checked.

10. Decision points

No decision points in this procedure.

11. Special situations

Situation	Action
Out of hours	Follow the same steps. Use the on-call contact on the wall of the area.

12. Escalation

Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.

13. Monitoring

Measure	Target	Frequency	Owner	If not met
Transfers with care level recorded	100%	Monthly	Dispatch lead	Escalate to clinical lead
Transfers matched to care level before departure	100%	Monthly	Clinical lead	Escalate to chief executive

14. Records

Record	Kept in	Retention
Record named in this document	Patient record or the area file	the period set by the facility’s records policy years

15. Training

Staff are trained in this document at induction and refreshed each year, with a recorded competency check.

16. Related documents

ID	Title	Use
PTR-FRM-003	Pre-transport clinical assessment	Assessment
PTR-REG-001	Escort and crew credential and pre-shift register	Register

17. Evidence

Reference	Note
E-009	ASF Expert Committee consensus.
E-006	ASF Policy Framework v1.2. Adapted.
E-009	ASF Expert Committee consensus.

18. Change history

Version	Date	What changed	Approval
1.0	the date of approval	First version	set Expert Committee approval

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References

Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)

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