Standards › Standard S6 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · PTR-SOP-008 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S6 (Patient transfers and referrals), criterion S6.37, S6.38, S6.39
At a glance
- PPE is carried in every vehicle and used at every patient contact.
- Patients with a known or suspected transmission risk are isolated under the written protocol.
- Sharps and clinical waste go through the written route, with containers on each vehicle.
- Record each isolation and each waste disposal.
- Stop and get help straight away if: a patient with a known transmission risk is moved with no isolation, or PPE is not carried.
1. Purpose
To stop the spread of infection between patients, crew and the public during transfer (S6.37, S6.38, S6.39).
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
Sharps and clinical waste that are not disposed of correctly injure crew and cleaners. A written disposal route and containers on the vehicle keep the risk low.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Crew lead | Applies isolation and checks PPE | Trained crew |
| Infection control lead | Owns the protocol and the waste route | Clinician |
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. Check PPE.
- Check the PPE is in the vehicle at the start of each shift.
- Use PPE at every patient contact.
Key point: PPE is used, not just carried.
Step 2. Isolate.
- Identify the transmission risk at the assessment.
- Apply the isolation protocol set for that risk and tell the receiver.
Key point: The receiver is told.
Step 3. Dispose.
- Put sharps in the container on the vehicle.
- Take the waste through the written route to the receiving facility or the contracted disposal.
Key point: No sharps in the bin.
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 |
|---|---|---|---|---|
| Vehicles with PPE in place at shift start | 100% | Monthly | Crew lead | Escalate to clinical lead |
| Known-risk patients isolated in transit | 100% | Monthly | Infection control 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-005 | Vehicle cleaning and disinfection checklist | Checklist |
| HOS-SOP-014 | Healthcare-associated infection surveillance and response | Surveillance |
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 |
E-learning for this document
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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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