Standards › Standard 35 › Policies
Policy · CRT-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 35.4
At a glance
- Each sedated patient has a sedation level target set and recorded (CRT-FRM-002).
- Delirium is screened at the set interval.
- Sedation is reviewed daily and reduced to the clinical need.
- Non-pharmacological delirium measures are used first.
- Stop and get help straight away if: a patient is kept on deep sedation with no daily review.
1. Purpose
To keep sedation as light as safe and to find and treat delirium early (35.4).
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
Deep sedation keeps a patient still but can cause delirium, and sedation left running too long prolongs ventilation. A protocol that sets the target and screens for delirium keeps the patient awake enough and safe.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Intensivist | Sets the protocol and reviews sedation daily | Clinical director |
| Bedside nurse | Screens for delirium and records the sedation level | Intensivist |
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. Target.
- Set the sedation level target for the patient.
Key point: Targeted.
Step 2. Screen.
- Screen for delirium at the set interval and record the result (CRT-FRM-002).
Key point: Screened.
Step 3. Review.
- Review the sedation daily and reduce it to the clinical need.
Key point: Reviewed.
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 |
|---|---|---|---|---|
| Sedated patients with a daily sedation review | 100% | Monthly | Intensivist | 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 |
|---|---|---|
| CRT-FRM-002 | Sedation and delirium screening chart | 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
No e-learning course is linked to this document yet.
Planned course: No e-learning course is linked to this criterion yet. A course is planned to cover it.
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)