Standards › Standard 35 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · CRT-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 35.1
At a glance
- Every critical care patient is monitored continuously at the level set for their condition (CRT-FRM-001).
- Alarm limits are set for each patient and recorded.
- Every alarm is responded to, and any alarm switched off is recorded with a reason.
- Equipment is checked at the start of each shift.
- Stop and get help straight away if: a critical care patient is left with alarms off or no monitoring record.
1. Purpose
To make sure each critical care patient’s physiology is watched continuously and that alarms reach a person who can act (35.1).
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 critically ill patient can deteriorate in minutes. Continuous monitoring, with alarms set to the patient’s acuity, shows the change while there is still time to act.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Critical care lead nurse | Owns the monitoring standard and the alarm settings | Clinical director |
| Bedside nurse | Sets alarm limits, responds to alarms and records them | 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. Set.
- Set the monitoring level and individual alarm limits for the patient’s condition.
Key point: Set.
Step 2. Monitor.
- Monitor continuously and respond to every alarm (CRT-FRM-001).
Key point: Monitored.
Step 3. Check.
- Check equipment and alarm settings at the start of each shift and record any alarm switched off with a reason.
Key point: Checked.
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 |
|---|---|---|---|---|
| Patients with continuous monitoring and recorded alarm limits | 100% | Weekly | 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 |
|---|---|---|
| CRT-FRM-001 | Monitoring and alarm record | Record |
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)