Standards › Standard S6 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · PTR-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S6 (Patient transfers and referrals), criterion S6.1, S6.2, S6.4, S6.24, S6.29
At a glance
- Write a plan for every transfer, naming the party responsible at each segment.
- State the handover point where our responsibility ends.
- Cover route or flight, timings, crew, escort, equipment and what happens if the transfer fails midway.
- Plan the ground journey to and from the airport as part of the transfer.
- Stop and get help straight away if: a transfer departs with no plan, or with a segment whose responsible party is not named.
1. Purpose
To make responsibility, timing and contingency clear for every segment of a transfer before it starts (S6.1, S6.2, S6.4, S6.24, S6.29).
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 vehicle that breaks down or is in an accident leaves the patient exposed. A written contingency plan with a backup vehicle or service keeps care going.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Dispatch lead | Writes and holds the plan | Trained dispatcher |
| Clinical lead | Approves the clinical parts | 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. Write the plan.
- Complete PTR-FRM-002 for the whole journey.
- Name the responsible party for each segment: pickup, ground to airport, air, destination airport, ground to the receiving facility.
Key point: Responsibility is named, not implied.
Step 2. Set the handover points.
- Write the handover point where our responsibility ends, for each change of segment.
Key point: One handover point per change.
Step 3. Plan the failure.
- Write what happens if the transfer fails midway or the escort cannot continue.
- Name the alternative escort or the diversion point.
Key point: The plan must cover failure.
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 |
|---|---|---|---|---|
| Transfers with a complete plan | 100% | Monthly | Dispatch lead | Escalate to clinical lead |
| Segments with a named responsible party | 100% | Monthly | Dispatch lead | Escalate to clinical lead |
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 |
|---|---|---|
| PTR-FRM-002 | Transfer plan | Plan form |
| PTR-SOP-004 | Air transport planning and authorisation | Air |
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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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)