Standards › Standard 26 › Plans and templates
Plan · DIA-PLN-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 26.8
At a glance
- Plan the response to low blood pressure, air in the blood line, allergic reaction and cardiac arrest during dialysis.
- Staff on each shift are trained and the equipment is ready (EQP-REG-001).
- Rehearse the response at least twice a year (DIA-FRM-006).
- A session does not run with no one trained to respond.
- Stop and get help straight away if: a patient collapses during dialysis with no one trained to respond.
1. Purpose
To make sure the unit can respond to the emergencies that occur during dialysis, and rehearses the response (26.8).
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
Dialysis patients can have a sudden drop in blood pressure, a cardiac arrest or other emergencies during treatment. Staff must be trained and the equipment ready for them.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Dialysis unit lead | Owns the plan and the rehearsal | Clinician |
| Shift nurse in charge | Leads the response on shift | Clinician |
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. Plan.
- Plan the response for each emergency, with the equipment and the staff who respond.
Key point: Planned.
Step 2. Staff.
- Confirm trained staff are on each shift before a session starts.
Key point: Staffed.
Step 3. Rehearse.
- Rehearse the response twice a year and record it on DIA-FRM-006.
Key point: Rehearsed.
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 |
|---|---|---|---|---|
| Shifts with trained staff for emergency response | 100% | Monthly | Dialysis unit lead | Escalate to medical 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 |
|---|---|---|
| DIA-FRM-006 | Emergency rehearsal record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on ISO 23500:2019 (fluids for haemodialysis) and the KDIGO Clinical Practice Guideline for Hemodialysis Adequacy (2015 update). |
| 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)