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PTR-POL-001: Transfer mode decision and right to refuse

Standards › Standard S6 › Policies

Policy · PTR-POL-001 · Version 1.0 · Approved by the ASF Expert Committee

Supports: System S6 (Patient transfers and referrals), criterion S6.46, S6.28

At a glance

  • The transfer mode (ground, air or escorted commercial flight) is decided by the named clinical lead.
  • The crew or escort may refuse a transfer judged unsafe, without penalty.
  • A diversion to the nearest appropriate facility is made when the condition or route requires it.
  • Every decision is recorded with its reason.
  • Stop and get help straight away if: a transfer goes ahead after a crew member has judged it unsafe, or a mode is chosen with no named decision maker.

1. Purpose

To make it clear who decides how a patient travels, and to protect the crew and the patient when a transfer is unsafe (S6.46, S6.28).

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

If the planned facility cannot take the patient, the crew must go to the next best one without delay. A set rule for diversion stops the crew from losing time arguing about where to go.

5. Responsibilities

Role Responsibility Competence
Clinical lead Decides the mode and approves any diversion Clinician
Crew and escort May refuse an unsafe transfer and record why Trained crew
Accountable manager Protects anyone who refuses in good faith Management

6. Materials and equipment

Item Requirement Condition
Records and forms named in this document Current version Checked before use

7. Safety

8. Before you start

9. Procedure

Step 1. Decide the mode.

  • Choose ground, air or escorted commercial flight based on the assessed needs.
  • Record the decision and the reason.

Key point: One named decision maker.

Step 2. Refuse if unsafe.

  • If the crew or escort judges the transfer unsafe, they stop it and tell dispatch.
  • Record the reason on the transfer log.

Key point: Refusal is protected.

Step 3. Divert.

  • If the patient deteriorates or the route is blocked, divert to the nearest appropriate facility.
  • Record the diversion and the receiver’s name.

Key point: The nearest appropriate place, not the planned one.

10. Decision points

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

13. Monitoring

Measure Target Frequency Owner If not met
Transfers with recorded mode decision 100% Monthly Clinical lead Escalate to chief executive
Refusals recorded with reason and no penalty 100% Quarterly Accountable manager Escalate to chief executive

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

16. Related documents

ID Title Use
AMT-SOP-001 Transfer logging, handover and record keeping Log
PTR-SOP-001 Transfer planning Plan

17. Evidence

Reference Note
E-009 ASF Expert Committee consensus.
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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