PTR-SOP-006: In-transit monitoring, deterioration and dispatch updates

Standards › Standard S6 › Standard operating procedures (SOPs)

Standard operating procedure (SOP) · PTR-SOP-006 · Version 1.0 · Approved by the ASF Expert Committee

Supports: System S6 (Patient transfers and referrals), criterion S6.25, S6.26, S6.31

At a glance

Monitor the patient continuously at a level matched to their condition.
Recognise deterioration and act on the set plan.
Keep dispatch informed of the patient’s status throughout.
Record every observation and every action.
Stop and get help straight away if: a patient deteriorates with no action recorded, or dispatch is not informed of a change in status.

1. Purpose

To catch a patient getting worse during transfer and respond with a plan (S6.25, S6.26, S6.31).

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

Dispatch and the receiving team need to know how the patient is doing during the journey. Regular updates let them prepare, and let them act if something goes wrong.

5. Responsibilities

Role	Responsibility	Competence
Crew lead	Monitors and leads the response	Trained crew
Dispatch lead	Receives updates and supports the crew	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. Monitor.

Record observations at the interval set for the care level.
Watch for the signs of deterioration named in the plan.

Key point: Interval matches the condition.

Step 2. Respond.

If a sign appears, follow the response plan in HOS-SOP-002 and call the clinical lead.
Record the time and the action.

Key point: A sign is an action.

Step 3. Update dispatch.

Call dispatch at each set point and at any change in status.

Key point: Dispatch always knows.

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
Observations recorded at the set interval	At least 70%	Monthly	Crew lead	Escalate to clinical lead
Deterioration with recorded response	100%	Monthly	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
HOS-SOP-002	Vital signs and deterioration response	Response
PTR-SOP-007	Structured handover at each change of segment	Handover

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)

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