Standards › Standard 35 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · CRT-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 35.5
At a glance
- Family receive a regular update on the patient’s condition (CRT-FRM-003).
- Updates are given in understandable language and questions are answered.
- The family presence policy is applied and any restriction is recorded with a reason.
- The family are told who to ask for updates.
- Stop and get help straight away if: a family is denied information for days with no reason recorded.
1. Purpose
To keep families informed and involved while protecting the patient’s care (35.5).
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
Families of patients in intensive care are often frightened and cut off. Regular, understandable updates and a clear policy on presence reduce distress and help the team work with them.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Critical care lead nurse | Owns the family policy and presence rules | Clinical director |
| Bedside nurse and doctor | Give the family regular updates and record 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. Agree.
- Agree with the family how and when they will get updates, and who will give them.
Key point: Agreed.
Step 2. Update.
- Give the update in plain language and record it (CRT-FRM-003).
Key point: Updated.
Step 3. Review presence.
- Apply the presence policy and record any restriction and its review.
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 |
|---|---|---|---|---|
| Families with regular updates recorded | 95% | Monthly | 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-003 | Family update 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
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)