Standards › Standard 9 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · FLD-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 9.2
At a glance
- Triage uses the same recognised tool at peak volume as on quiet days.
- A team lead is named for each triage area in every shift.
- Triage continues at peak; it is not paused to treat.
- Surge triage is rehearsed with the mass-casualty plan (HOS-PLN-001).
- Stop and get help straight away if: triage stops, or patients are treated without being triaged at peak volume.
1. Purpose
To keep sorting patients by clinical need when the numbers are high (9.2).
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 patients arrive in numbers, the unit must still sort them by clinical need. A triage system that works only on quiet days fails the patients who need it most.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Triage team lead | Runs triage in each shift | Clinician |
| Field unit lead | Calls surge and rehearses it | 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. Sort.
- Triage every arrival with HOS-SOP-001 and record it on HOS-FRM-001.
Key point: Every arrival is sorted.
Step 2. Keep going at peak.
- Keep one triage lead on duty at all times, even when treatment areas are full.
Key point: Triage does not stop.
Step 3. Call a surge.
- Call the surge when arrivals exceed capacity, and follow HOS-PLN-001.
Key point: Surge is called early.
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 |
|---|---|---|---|---|
| Peak-hour arrivals triaged | 100% | Each shift | Triage team lead | Escalate to field unit 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 |
|---|---|---|
| HOS-FRM-001 | Triage record and log (existing, reused) | Record |
| HOS-PLN-001 | Mass-casualty and utility failure plan (existing, reused) | Plan |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on WHO classification and minimum standards for emergency medical teams (2013). |
| 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)