Standards › Standard S2 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · AMC-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S2 (Ambulatory clinic), criterion S2.3
At a glance
- Call for help at once when a patient becomes unwell in the clinic.
- Start resuscitation with the clinic equipment while help arrives.
- Transfer the patient to the named hospital under the written agreement.
- Send the patient record with them, and record the transfer.
- Stop and get help straight away if: a patient needs urgent transfer and no transfer route or agreement is in place.
1. Purpose
To make sure the clinic can respond to an emergency, and get a patient who needs admission to the named hospital safely and quickly (S2.3).
2. Scope
| Applies to | All clinical and reception staff on clinic days |
| Locations | All rooms of the clinic |
| When | Any emergency during clinic hours, and any procedure where a complication may occur |
| Does not apply to | Routine referrals that are not urgent (see HOS-SOP-010) |
3. Definitions
| Term | Meaning |
|---|---|
| Named hospital | The hospital named in the written transfer agreement |
| Transfer agreement | A signed agreement with the named hospital on acceptance and route |
4. Background
When a patient stops breathing, minutes matter. Equipment that is missing or broken, or staff without current life-support training, cost lives.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Lead clinician on the day | Leads the response and decides on transfer | Doctor with resuscitation training |
| Nurse | Starts resuscitation equipment and records the time | Current life support |
| Reception | Calls the emergency services and the named hospital | Trained in the call route |
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. Call for help.
- Use the call route posted in the room.
- Call the emergency number and the named hospital.
Key point: Call first, then treat.
Step 2. Start care.
- Start resuscitation or first aid with the clinic equipment.
- Record the time of each step.
Key point: The clinic is never without care while waiting.
Step 3. Transfer.
- Transfer under the written agreement.
- Send the record and a copy of the medicines given.
Key point: The receiving team needs the record.
Step 4. Record and review.
- Record the event on the incident system the same day.
- Review it within 2 weeks.
Key point: Every event is a learning point.
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 |
|---|---|---|---|---|
| Emergency drills in the last 12 months | 100% | Yearly | Clinic lead | Escalate to chief executive |
| Transfers with the record sent | 100% | Each transfer | Clinic lead | Escalate to 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-015 | Resuscitation equipment checks | Equipment checks |
| HOS-REG-004 | Rehearsal and drill record | Drill record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Transfer time limits to be confirmed by the Committee and the named hospital. |
| 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)