Standards › Standard 35 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · CRT-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 35.3
At a glance
- A structured early warning score is used to detect deterioration.
- A trigger score brings a rapid response within the defined time.
- Any staff member can call the rapid response team without seeking permission.
- Every response and escalation is recorded (HOS-FRM-002).
- Stop and get help straight away if: a trigger score is reached and no one is called.
1. Purpose
To make sure a patient who starts to deteriorate is seen quickly by a team that can act (35.3, 35.7).
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
Patients in intensive care often show early warning signs hours before they arrest. A structured scoring system, with a rapid response route, catches them in time.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Critical care lead nurse | Owns the trigger thresholds and the response standard | Clinical director |
| Any staff member | Calls the rapid response team at a trigger score | Critical care lead nurse |
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. Score.
- Record the early warning score at the set frequency (HOS-FRM-002).
Key point: Scored.
Step 2. Call.
- At a trigger score, call the rapid response team at once.
Key point: Called.
Step 3. Record.
- Record the response, the clinician and the outcome.
Key point: Recorded.
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 |
|---|---|---|---|---|
| Triggers with response within the defined time | 100% | Monthly | Critical care lead nurse | Escalate to the clinical director |
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-SOP-002 | Vital signs and deterioration response (existing) | Procedure |
| HOS-FRM-002 | Observation and early warning chart (existing) | Form |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the Surviving Sepsis and critical care monitoring guidance, the NEWS2 early warning score (Royal College of Physicians, 2017), the Lancet Commission on Palliative Care (2018), and the WHO Global Patient Safety Action Plan 2021–2030. |
| 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
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)