Standards › Standard S6 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · PTR-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S6 (Patient transfers and referrals), criterion S6.7, S6.8
At a glance
- Neonatal and paediatric transfers use a specialist team and equipment.
- Critically ill patients travel with staff and equipment matched to their condition.
- Confirm the receiving specialist unit has accepted before departure.
- Record the specialist arrangement on the plan.
- Stop and get help straight away if: a neonate, child or critically ill patient is moved without the specialist team or matched equipment.
1. Purpose
To send the most vulnerable patients with the team and equipment they need (S6.7, S6.8).
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
Newborns and children are not small adults. Their transfers need equipment, drugs and staff trained for their size and condition, or the risk of harm rises sharply.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical lead | Arranges the specialist team and equipment | Clinician |
| Dispatch lead | Confirms specialist cover on the plan | Trained dispatcher |
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. Arrange the team.
- Book the neonatal or paediatric team for the transfer.
- Record the team on the plan.
Key point: Specialist cover is booked, not hoped for.
Step 2. Match equipment.
- Check the specialist equipment and drugs for the patient’s weight and condition before departure.
Key point: Equipment matches the patient.
Step 3. Confirm acceptance.
- Confirm the specialist unit accepts the patient before departure, and record the name of the person who accepted.
Key point: Accepted before moved.
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 |
|---|---|---|---|---|
| Neonatal and paediatric transfers with specialist team | 100% | Quarterly | Clinical lead | 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
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| PTR-SOP-002 | Care level classification and crew matching | Matching |
| HOS-SOP-015 | Resuscitation equipment checks | Equipment |
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)