Standards › Standard 36 › Policies
Policy · ED-POL-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 36.2
At a glance
- A resuscitation area is available at all times (ED-REG-001).
- Equipment and drugs are checked on the documented schedule.
- Staff on every shift are trained in resuscitation.
- Any item found missing or out of date is replaced at once and recorded.
- Stop and get help straight away if: the resuscitation area is used with drugs or equipment out of date.
1. Purpose
To make sure the resuscitation area can be used at once, with complete equipment and drugs (36.2).
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
A resuscitation area that is not ready when a patient arrives in cardiac arrest costs minutes that cannot be recovered. Equipment and drugs checked on a schedule are ready when needed.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Emergency department lead | Owns the readiness standard and the schedule | Clinical director |
| Nurse in charge of the shift | Carries out the check and records it | Emergency department lead |
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. Check.
- Check the resuscitation area on the schedule against the equipment and drug list.
Key point: Checked.
Step 2. Replace.
- Replace any missing or out-of-date item at once.
Key point: Replaced.
Step 3. Record.
- Record the check in the readiness register (ED-REG-001).
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 |
|---|---|---|---|---|
| Resuscitation checks completed on schedule | 100% | Weekly | Emergency department lead | 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 |
|---|---|---|
| ED-REG-001 | Resuscitation area readiness register | Register |
| HOS-SOP-015 | Resuscitation equipment checks (existing) | Procedure |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Emergency Care Systems framework and the Emergency Triage Assessment and Treatment guidance, the WHO Global Patient Safety Action Plan 2021–2030 for handover, and the ASF Hospital standard for senior clinician responsibility. |
| 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)