Standards › Standard 7 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · EDP-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 7.3
At a glance
- Choose the nearest resource that is suitable for the priority.
- Dispatch within the set time, and record the time.
- Give the caller pre-arrival instructions for the condition.
- Keep the caller on the line until help arrives or the call is handed over.
- Stop and get help straight away if: a resource is not dispatched for a call, or the caller is ended without instructions.
1. Purpose
To send the right help quickly, and to keep the caller safe while it comes (7.3).
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
The nearest suitable resource must reach the caller within a set time. Measuring dispatch time, and giving the caller clear instructions while they wait, closes the gap between call and arrival.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Dispatcher | Chooses and sends the resource | Trained dispatcher |
| Call taker | Gives the pre-arrival instructions | Trained call taker |
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. Choose.
- Choose the nearest resource suitable for the priority and check its status.
Key point: Nearest and suitable.
Step 2. Send.
- Dispatch and record the time (EDP-REG-001).
Key point: The time is measured.
Step 3. Instruct.
- Give pre-arrival instructions for the condition, as the protocol sets, until help arrives.
Key point: The caller is guided.
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 |
|---|---|---|---|---|
| Dispatches within the set time | At least 90% | Monthly | Operations manager | 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 |
|---|---|---|
| EDP-REG-001 | Dispatch time register | Register |
| PTR-SOP-006 | In-transit monitoring and dispatch updates | Updates |
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
- Emergency Response During Transport (MT-06)
- Vehicle & Equipment Readiness for ASF Accreditation (MT-01)
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)