Standards › Standard 56 › Standard operating procedures (SOPs)
SOP · CAR-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 56.2
At a glance
- Each cardiac procedure follows the written protocol for access, sedation, contrast and radiation (CTR-SOP-001, RAD-POL-001).
- A cardiac emergency team is available for each procedure, and the emergency plan is in place (FW-PLN-001).
- Each procedure is logged with its key steps and outcome (CAR-REG-001).
- Each adverse event is recorded and reviewed (PRO-FRM-006).
- Stop and get help straight away if: a cardiac procedure starts without the emergency team and equipment ready, or without a recorded pre-procedure check.
1. Purpose
To make sure cardiac procedures are done under a defined safety standard, with an emergency team ready (56.2).
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
To make sure cardiac procedures are done under a defined safety standard, with an emergency team ready (56.2).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Interventional cardiologist | Leads each procedure under the protocol | Clinical lead |
| Cath lab nurse | Checks the team and equipment and logs the procedure | Interventional cardiologist |
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. Prepare.
- Check the team, the emergency equipment and the contrast and radiation plan before the procedure.
Key point: Prepared.
Step 2. Procedure.
- Carry out the procedure under the protocol and record the key steps (CAR-REG-001).
Key point: Done.
Step 3. Review.
- Record any adverse event (PRO-FRM-006) and review it.
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 |
|---|---|---|---|---|
| Procedures with the pre-procedure check recorded | 100% | Monthly | Clinical lead | Stop the procedure until checked |
| Adverse events recorded and reviewed | 100% | Monthly | Clinical lead | Review at once |
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 |
|---|---|---|
| CAR-REG-001 | Cardiac procedure log | Register |
| CTR-SOP-001 | Contrast media safety protocol (existing, reused) | SOP |
17. Evidence
| Reference | Note |
|---|---|
| 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
- Cardiology & Cardiac Catheterization (AMB-14)
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)