Standards › Standard S6 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · PTR-SOP-012 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S6 (Patient transfers and referrals), criterion S6.28, S6.29, S6.30
At a glance
- Every vehicle has a breakdown and accident plan.
- A diversion goes to the nearest appropriate facility.
- The transport service has a mass casualty and surge plan.
- Each contingency is tested each year.
- Stop and get help straight away if: a vehicle breaks down or crashes and the crew has no plan to follow.
1. Purpose
To keep patients safe when something goes wrong on the road or in the air, and when demand surges (S6.28, S6.29, S6.30).
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
When many patients need transport at once, an unplanned response leaves some patients waiting far too long. A surge plan sets who does what and how the service scales up.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Dispatch lead | Owns the contingency plans and the surge plan | Trained dispatcher |
| Crew lead | Acts on the plan on the road | 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. Breakdown or accident.
- Make the patient safe, call dispatch and request a replacement vehicle.
- Record the event.
Key point: Patient first, then the vehicle.
Step 2. Divert.
- Divert to the nearest appropriate facility and tell dispatch and the receiver.
Key point: Nearest appropriate.
Step 3. Surge.
- Follow the mass casualty and surge plan (HOS-PLN-001 adapted for transport) and test it each year.
Key point: Tested before needed.
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 contingency plan on board | 100% | Quarterly | Dispatch lead | Escalate to chief executive |
| Surge plan tested in the last 12 months | 100% | Yearly | Dispatch 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 |
|---|---|---|
| HOS-PLN-001 | Mass-casualty and utility failure plan | Surge |
| HOS-REG-004 | Rehearsal and drill record | Drill |
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)