Standards › Standard S6 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · PTR-SOP-004 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S6 (Patient transfers and referrals), criterion S6.9, S6.23
At a glance
- Air transport is authorised by the clinical lead before it is booked.
- Confirm seats for the patient and escort, equipment, oxygen and the airline’s acceptance.
- Only use an operator with a current contract and aviation certificate.
- Record the authorisation and the confirmations.
- Stop and get help straight away if: an air transfer is booked or flown with no authorisation, or with the airline’s acceptance not confirmed.
1. Purpose
To make air transport planned, authorised and controlled (S6.9, S6.23).
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
A patient on a commercial flight needs seats, oxygen and medical equipment agreed with the airline in advance. Without that agreement, the patient can be refused boarding or travel without what they need.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical lead | Authorises the air transfer | Clinician |
| Dispatch lead | Books and confirms the arrangements | Trained dispatcher |
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. Authorise.
- The clinical lead signs the authorisation with the reason for air transport.
Key point: Air is a decision, not a default.
Step 2. Confirm.
- Confirm seats, equipment, oxygen and the airline’s acceptance for the patient’s condition, in writing.
Key point: Confirmed in writing.
Step 3. Check.
- Complete the aircraft and cabin check (PTR-FRM-004) before departure.
Key point: Checked before it flies.
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 |
|---|---|---|---|---|
| Air transfers with authorisation before booking | 100% | Monthly | Clinical lead | Escalate to chief executive |
| Air transfers with airline acceptance confirmed | 100% | Monthly | Dispatch lead | Escalate to clinical lead |
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-004 | Aircraft and cabin check | Check form |
| PTR-POL-002 | Transfer insurance, cross-border and data sharing rules | Insurance |
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)