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Standard 42: Critical Interfacility Transfer (Version 11)

Standards › ASF Health Standards Version 11 › Standard 42

Standard 42

Critical Interfacility Transfer

Patient transfer between facilities and services, by road, air or commercial flight, with a named accountable party at every segment.

46
criteria
6
documents
11
e-learning courses
9
guidelines

How to read the colours

Red: Must. Required in every setting. Criteria that protect life are always red.

Green: Medium. Required, adapted to what a humanitarian or transition setting can realistically do.

Yellow: Minimum. The lowest acceptable level in a humanitarian setting, where resources are very limited.

Each criterion is shown in three settings: Humanitarian settings, Transition and fragile, and Standard. In standard settings, every criterion is Must.

Every policy, SOP, form, checklist and course on this page is a draft to help you. Adapt it to your transport service, write your own, or upload your own documents. What the assessor checks is that the standard is met and that you can show how.

Criteria on this page

42.1 · 42.2 · 42.3 · 42.4 · 42.5 · 42.6 · 42.7 · 42.8 · 42.9 · 42.10 · 42.11 · 42.12 · 42.13 · 42.14 · 42.15 · 42.16 · 42.17 · 42.18 · 42.19 · 42.20 · 42.21 · 42.22 · 42.23 · 42.24 · 42.25 · 42.26 · 42.27 · 42.28 · 42.29 · 42.30 · 42.31 · 42.32 · 42.33 · 42.34 · 42.35 · 42.36 · 42.37 · 42.38 · 42.39 · 42.40 · 42.41 · 42.42 · 42.43 · 42.44 · 42.45 · 42.46

42.1Each Segment Has a Named Accountable PartyHumanitarian settings: MustTransition and fragile: MustStandard: Must

Every leg of the transfer, including ground, air and airport segments, names one accountable person for the patient during that leg.

Humanitarian settings
Must
Transition and fragile
Must
Standard
Must

Why it matters. When no one is named for a leg, a patient can be left unattended between two services.

Questions the surveyor asks

  • Is there a named person for every segment? The name is written in the plan, not assumed.
  • Can the named person be reached during the leg? A phone or radio contact is recorded.
  • Is the accountable person changed only by a recorded handover? No silent change of responsibility.

How the surveyor verifies this criterion

Sample. Five transfers from the last 3 months with all their segments.

1. Named person per segment

Method. Check each sampled plan for one name per leg.

Evidence to show. Referral and evacuation route plan (FLD-PLN-001).

Pass when. Every segment in the sample has one named person.

2. Contact is recorded

Method. Check for a contact entry per leg.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Each leg has a contact recorded.

3. Changes are recorded

Method. Check for recorded handovers between legs.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Each change of responsibility is recorded.

Good practice. One named accountable person per segment, reachable, with recorded changes.

Immediate fail (any one means the criterion is not met). A transfer leg has no named person.

Partial because. Names are recorded for some legs but not all.

Staff, training and documents

Documents

E-learning

42.2The End of the Provider’s Responsibility Is Written DownHumanitarian settings: MustTransition and fragile: MustStandard: Must

The point at which the sending provider’s responsibility ends is written in the plan and confirmed at handover.

Humanitarian settings
Must
Transition and fragile
Must
Standard
Must

Why it matters. Without a written end point, both services can assume the other is responsible.

Questions the surveyor asks

  • Is the end point of responsibility written? A named location and time.
  • Is it confirmed by the receiving party? A signature or verbal confirmation recorded.
  • Is it in the transfer record? Not only in a verbal briefing.

How the surveyor verifies this criterion

Sample. Five transfer records from the last 3 months.

1. End point written

Method. Check each sampled record for a written end point.

Evidence to show. Referral and evacuation route plan (FLD-PLN-001).

Pass when. Each sampled record names the end point.

2. Confirmed by receiver

Method. Check the record for receiving confirmation.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Each sampled record has a confirmation.

3. In the transfer record

Method. Check the record itself, not a briefing note.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. The end point appears in every sampled record.

Good practice. End point written, confirmed and recorded for every transfer.

Immediate fail (any one means the criterion is not met). No end point is written.

Partial because. The end point is written but not confirmed by the receiver.

Staff, training and documents

Documents

E-learning

42.3The Receiving Facility or Service Accepts the Patient Before DepartureHumanitarian settings: MustTransition and fragile: MustStandard: Must

The receiving clinician accepts the patient before the transfer leaves, and the acceptance is recorded with the time and name.

Humanitarian settings
Must
Transition and fragile
Must
Standard
Must

Why it matters. A patient sent without acceptance can arrive where no bed or clinician is ready.

Questions the surveyor asks

  • Is acceptance obtained before departure? Acceptance is a precondition, not a courtesy.
  • Is the acceptance recorded with time and name? The name of the accepting clinician is needed.
  • Is the destination ready for the patient? Bed, staff and equipment confirmed.

How the surveyor verifies this criterion

Sample. Five transfers from the last 3 months.

1. Acceptance before departure

Method. Check each record for an acceptance time before the departure time.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Acceptance is earlier than departure in every sampled record.

2. Name and time recorded

Method. Check for the name and time of the accepting clinician.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Every acceptance has a name and time.

3. Destination ready

Method. Check the record for a confirmed bed and staff.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. Each sampled destination is confirmed as ready.

Good practice. Acceptance recorded before departure, with the destination confirmed ready.

Immediate fail (any one means the criterion is not met). Patients are sent with no acceptance.

Partial because. Acceptance happens but is not recorded with name and time.

Staff, training and documents

Documents

E-learning

42.4The Transfer Plan Is Written Before Departure, With a Back-Up PlanHumanitarian settings: MediumTransition and fragile: MediumStandard: Must

A written transfer plan exists before departure. It names a back-up destination and a back-up route, and the crew knows both.

Humanitarian settings
Medium
Transition and fragile
Medium
Standard
Must

Why it matters. Plans fail when conditions change. A written back-up lets the crew change course without delay.

Questions the surveyor asks

  • Is the plan written before departure? Written at the time of decision, not reconstructed later.
  • Does it name a back-up destination? A second facility, with its contact.
  • Does it name a back-up route? A second road or flight path.

How the surveyor verifies this criterion

Sample. Ten transfer plans from the last 3 months.

1. Plan written before departure

Method. Check each plan date against the departure time.

Evidence to show. Referral and evacuation route plan (FLD-PLN-001).

Pass when. Every sampled plan is dated before departure.

2. Back-up destination named

Method. Check each plan for a named back-up destination.

Evidence to show. Referral and evacuation route plan (FLD-PLN-001).

Pass when. At least 9 of 10 sampled plans name a back-up destination.

3. Crew knows the back-up

Method. Ask a crew member to name the back-up destination and route.

Evidence to show. Referral and evacuation route plan (FLD-PLN-001).

Pass when. The crew names both back-ups correctly.

Good practice. A written plan before departure, with a named back-up destination and route known to the crew.

Immediate fail (any one means the criterion is not met). No plan is written before departure.

Partial because. The plan exists but the back-up is missing or unknown to the crew.

Staff, training and documents

Documents

E-learning

42.5Pre-Transport Clinical Assessment CompletedHumanitarian settings: MustTransition and fragile: MustStandard: Must

A clinical assessment is completed and recorded before the patient leaves the sending facility.

Humanitarian settings
Must
Transition and fragile
Must
Standard
Must

Why it matters. A patient who deteriorates in transit with no baseline cannot be assessed properly.

Questions the surveyor asks

  • Is an assessment done before transport? The assessment is recent and complete.
  • Are vital signs recorded? A full set of observations is recorded.
  • Is the assessment signed? The name of the assessor is on the record.

How the surveyor verifies this criterion

Sample. Twenty transfer records from the last 3 months.

1. Assessment completed

Method. Check each record for a pre-transport assessment.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Every sampled record has an assessment.

2. Observations recorded

Method. Check the vital signs in each assessment.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. A full set of vital signs is recorded in each sampled assessment.

3. Signed

Method. Check for the assessor name and signature.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Each assessment is signed.

Good practice. A complete, signed assessment with full observations before every transfer.

Immediate fail (any one means the criterion is not met). A patient is transported with no assessment.

Partial because. An assessment exists but is incomplete or unsigned.

Staff, training and documents

Documents

E-learning

42.6Transfer Level Matches Patient NeedHumanitarian settings: MustTransition and fragile: MustStandard: Must

The transport level, whether basic, intermediate or critical, matches the patient’s clinical need and is recorded.

Humanitarian settings
Must
Transition and fragile
Must
Standard
Must

Why it matters. A patient sent at too low a level can deteriorate with no support, and one sent at too high a level uses scarce resources.

Questions the surveyor asks

  • Is the transport level recorded? Basic, intermediate or critical.
  • Does the level match the assessment? The reason for the level is written down.
  • Is the level reviewed if the condition changes? A change prompts a new decision.

How the surveyor verifies this criterion

Sample. Twenty transfers from the last 3 months with their assessments.

1. Level recorded

Method. Check each transfer record for a transport level.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Every sampled transfer has a recorded level.

2. Level matches need

Method. Compare the level with the assessment.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. At least 18 of 20 sampled levels match the assessment.

3. Review on change

Method. Check the record for a reviewed level after a change in condition.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Each sampled change in condition has a reviewed level.

Good practice. A recorded level that matches the assessment and is reviewed when the condition changes.

Immediate fail (any one means the criterion is not met). No transport level is recorded.

Partial because. The level is recorded but does not match the assessment.

Staff, training and documents

Documents

E-learning

42.7Critically Ill Patients Transported With Matched Staff and EquipmentHumanitarian settings: MediumTransition and fragile: MediumStandard: Must

Critically ill patients are transported with staff trained for critical care and with the equipment their condition needs.

Humanitarian settings
Medium
Transition and fragile
Medium
Standard
Must

Why it matters. A critically ill patient with an untrained crew or missing equipment can deteriorate quickly in transit.

Questions the surveyor asks

  • Is the crew trained for critical care? Training and competence recorded.
  • Is the critical equipment on board? Ventilator, monitor, drugs and oxygen as needed.
  • Is the equipment checked before departure? A check is recorded.

How the surveyor verifies this criterion

Sample. Ten critical transfers from the last 3 months.

1. Crew trained

Method. Check the crew record for critical-care training.

Evidence to show. Patient transport attendant / escort (ToR).

Pass when. Every sampled critical transfer has a trained crew member.

2. Equipment on board

Method. Check the vehicle or aircraft list against the patient’s needs.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. The required equipment is on board for each sampled transfer.

3. Checked before departure

Method. Check the pre-departure check record.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. A check is recorded before each sampled departure.

Good practice. Trained crew, critical equipment on board, and a check recorded before departure.

Immediate fail (any one means the criterion is not met). A critically ill patient is transported with no critical-care crew or equipment.

Partial because. Crew or equipment is present but the check is not recorded.

Staff, training and documents

Documents

E-learning

42.8Neonatal and Paediatric Transfers Use Specialist ArrangementsHumanitarian settings: MustTransition and fragile: MediumStandard: Must

Neonatal and paediatric transfers use specialist crews, equipment sized for the child, and an agreed plan with the receiving specialist unit.

Humanitarian settings
Must
Transition and fragile
Medium
Standard
Must

Why it matters. Children and newborns have different physiology and equipment needs. Adult arrangements can cause serious harm.

Questions the surveyor asks

  • Is the transfer done by a specialist crew? Trained for neonatal or paediatric care.
  • Is the equipment sized for the child? Sizes checked and recorded.
  • Is the receiving specialist unit agreed? A named unit accepts the child.

How the surveyor verifies this criterion

Sample. Five neonatal or paediatric transfers from the last 3 months.

1. Specialist crew

Method. Check each record for a specialist crew member.

Evidence to show. Patient transport attendant / escort (ToR).

Pass when. Every sampled transfer has a specialist crew.

2. Equipment sized

Method. Check the equipment record for paediatric sizes.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. Equipment sizes are recorded for each sampled transfer.

3. Receiving unit agreed

Method. Check the acceptance record.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. A named specialist unit has accepted each sampled child.

Good practice. Specialist crew, sized equipment and an accepting specialist unit for every child.

Immediate fail (any one means the criterion is not met). A child is transported with adult arrangements.

Partial because. Some transfers use specialist arrangements but not all.

Staff, training and documents

Documents

E-learning

  • Neonatal and Paediatric Transfers (PED-03): draft, not yet published (Must for paediatric transfers)
  • ASF Monitor Certification (MON-01) — content under review (Must for critical care staff)
42.9Air Transport Is Planned, Authorised and ControlledHumanitarian settings: MediumTransition and fragile: MediumStandard: Must

Air transport is planned, authorised by a named authority and controlled by a named coordinator from request to landing.

Humanitarian settings
Medium
Transition and fragile
Medium
Standard
Must

Why it matters. Air transport is high-risk and time-critical. Without authorisation and control, flights can be unsafe or delayed.

Questions the surveyor asks

  • Is the flight authorised? A named authority signs the decision.
  • Is a coordinator controlling the flight? A named person from request to landing.
  • Is the flight plan recorded? Route, timing and landing point.

How the surveyor verifies this criterion

Sample. Ten air transfers from the last 3 months.

1. Authorised

Method. Check each record for an authorisation signature.

Evidence to show. Fitness to travel and handover to the home-country clinician (ASF tool).

Pass when. Every sampled flight has a signed authorisation.

2. Controlled

Method. Check the coordinator name in each record.

Evidence to show. Referral and evacuation route plan (FLD-PLN-001).

Pass when. Each sampled flight has a named coordinator.

3. Flight plan recorded

Method. Check each record for route and timing.

Evidence to show. Referral and evacuation route plan (FLD-PLN-001).

Pass when. Each sampled flight has a recorded plan.

Good practice. Authorised, coordinated and recorded flights.

Immediate fail (any one means the criterion is not met). A flight is made with no authorisation.

Partial because. The flight is authorised but not coordinated or not recorded.

Staff, training and documents

Documents

E-learning

42.10Patient Consent Obtained and DocumentedHumanitarian settings: MustTransition and fragile: MustStandard: Must

The patient, or a legal representative, gives informed consent to the transfer, and the consent is documented before departure.

Humanitarian settings
Must
Transition and fragile
Must
Standard
Must

Why it matters. A transfer without consent breaches the patient’s rights and can harm trust in the whole service.

Questions the surveyor asks

  • Is consent obtained before departure? Given freely, after explanation.
  • Is the consent documented? A signed form or recorded verbal consent.
  • Is a representative used where the patient cannot consent? The representative is named.

How the surveyor verifies this criterion

Sample. Twenty transfers from the last 3 months.

1. Consent before departure

Method. Check each record for a consent time before departure.

Evidence to show. Fitness to travel and handover to the home-country clinician (ASF tool).

Pass when. Every sampled transfer has consent before departure.

2. Documented

Method. Check the consent form or recorded entry.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Every sampled consent is documented.

3. Representative named

Method. Check the record where the patient could not consent.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Each sampled representative is named.

Good practice. Consent before every transfer, documented and, where needed, given by a named representative.

Immediate fail (any one means the criterion is not met). A transfer is made with no consent and no representative.

Partial because. Consent is obtained but not documented.

Staff, training and documents

Documents

E-learning

42.11Crew Scope of Practice Matches Transfer AcuityHumanitarian settings: MediumTransition and fragile: MediumStandard: Must

Each crew member works within the scope of practice that matches the acuity of the transfer, and the scope is written down.

Humanitarian settings
Medium
Transition and fragile
Medium
Standard
Must

Why it matters. A crew member who works beyond their scope can cause harm, and one who is under-qualified can miss a deterioration.

Questions the surveyor asks

  • Is each crew member’s scope written? Their role and permitted procedures.
  • Does the crew match the acuity? The crew level equals the transfer level.
  • Is scope checked before each shift? A recorded check.

How the surveyor verifies this criterion

Sample. Ten transfers from the last 3 months with their crew lists.

1. Scope written

Method. Check each crew member’s file for a written scope.

Evidence to show. Patient transport attendant / escort (ToR).

Pass when. Every crew member has a written scope.

2. Crew matches acuity

Method. Compare each crew list with the transfer level.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. Each sampled crew matches the transfer level.

3. Checked before shift

Method. Check the shift record for a scope check.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Each sampled shift has a recorded check.

Good practice. Written scopes, crews matched to acuity, and checks before each shift.

Immediate fail (any one means the criterion is not met). A crew member works beyond their scope.

Partial because. Scopes are written but not checked before shifts.

Staff, training and documents

Documents

E-learning

42.12Minimum Crew Complement Written and AppliedHumanitarian settings: MustTransition and fragile: MediumStandard: Must

The minimum crew for each transfer type is written down and applied to every transfer.

Humanitarian settings
Must
Transition and fragile
Medium
Standard
Must

Why it matters. A transfer with too few staff cannot monitor, treat and drive at the same time.

Questions the surveyor asks

  • Is the minimum crew written? For each transfer type.
  • Is it applied to every transfer? No transfer leaves below the minimum.
  • Is a shortfall escalated? A recorded decision if the minimum cannot be met.

How the surveyor verifies this criterion

Sample. Twenty transfers from the last 3 months.

1. Minimum written

Method. Check the transport policy for a written minimum.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. The minimum is written for each transfer type.

2. Applied to every transfer

Method. Check each sampled crew list against the minimum.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. No sampled transfer is below the minimum.

3. Shortfall escalated

Method. Check for a recorded escalation where the minimum was not met.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Each shortfall is recorded and escalated.

Good practice. A written minimum, applied to every transfer, with shortfalls escalated.

Immediate fail (any one means the criterion is not met). Transfers leave with no minimum crew and no escalation.

Partial because. The minimum is written but not always applied.

Staff, training and documents

Documents

E-learning

42.13Escort Doctor Qualified and Credentialed for the Transfer TypeHumanitarian settings: MustTransition and fragile: MediumStandard: Must

The escort doctor is qualified and credentialed for the type of transfer, and the credential is checked before each flight or journey.

Humanitarian settings
Must
Transition and fragile
Medium
Standard
Must

Why it matters. An escort doctor without the right credential cannot manage the patient’s condition in transit.

Questions the surveyor asks

  • Is the escort doctor qualified? Qualification on file.
  • Is the credential specific to the transfer type? Air or ground, critical or intermediate.
  • Is the credential checked before each transfer? A recorded check.

How the surveyor verifies this criterion

Sample. Ten escort doctor assignments from the last 3 months.

1. Qualified

Method. Check each escort doctor’s file for a qualification.

Evidence to show. Flight physician (medevac) (ToR).

Pass when. Every sampled escort doctor has a qualification on file.

2. Credential matches transfer

Method. Check the credential against the transfer type.

Evidence to show. Fitness to travel and handover to the home-country clinician (ASF tool).

Pass when. Each sampled credential matches the transfer type.

3. Checked before transfer

Method. Check the record for a credential check before each transfer.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Each sampled transfer has a recorded check.

Good practice. Qualified escort doctors, with credentials matched and checked before each transfer.

Immediate fail (any one means the criterion is not met). An unqualified doctor escorts a patient.

Partial because. A doctor is qualified but the credential is not checked before transfer.

Staff, training and documents

Documents

E-learning

  • Emergency Response During Patient Transport (MT-06): draft, not yet published (Must for escort doctors)
42.14Escort Continuity to the Handover PointHumanitarian settings: MustTransition and fragile: MustStandard: Must

The escort stays with the patient from the start of the transfer to the named handover point, with no gap in responsibility.

Humanitarian settings
Must
Transition and fragile
Must
Standard
Must

Why it matters. A patient left without an escort during a change of vehicle or flight can be lost or harmed.

Questions the surveyor asks

  • Does the escort stay with the patient to the handover point? No gap in responsibility.
  • Is a change of escort recorded? A handover is recorded.
  • Is the handover point named? The place and time are written.

How the surveyor verifies this criterion

Sample. Ten transfers with a change of vehicle or flight from the last 3 months.

1. Escort stays

Method. Check each record for the escort at each change point.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. The escort is recorded at each change point in every sampled transfer.

2. Change recorded

Method. Check each change for a recorded handover.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Every change is recorded.

3. Handover point named

Method. Check the plan for the named handover point.

Evidence to show. Referral and evacuation route plan (FLD-PLN-001).

Pass when. Each sampled plan names the handover point.

Good practice. Continuous escort with recorded changes and named handover points.

Immediate fail (any one means the criterion is not met). The patient is left without an escort at any point.

Partial because. Escort is continuous but changes are not recorded.

Staff, training and documents

Documents

E-learning

  • Emergency Response During Patient Transport (MT-06): draft, not yet published (Must for escorts)
42.15Certification Current Before Each ShiftHumanitarian settings: MediumTransition and fragile: MediumStandard: Must

Every crew member holds current certification for the role, and the certification is checked before each shift.

Humanitarian settings
Medium
Transition and fragile
Medium
Standard
Must

Why it matters. Lapsed certification means a crew member is not authorised to perform their role.

Questions the surveyor asks

  • Is certification on file? Each crew member has a certificate.
  • Is it current? The expiry date is after the shift date.
  • Is it checked before each shift? A recorded check.

How the surveyor verifies this criterion

Sample. Twenty crew members from the last 3 months.

1. On file

Method. Check each crew file for a certificate.

Evidence to show. Patient transport attendant / escort (ToR).

Pass when. Every crew member has a certificate on file.

2. Current

Method. Compare each expiry date with the shift date.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. No sampled certificate has expired.

3. Checked before shift

Method. Check the shift record for a certification check.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Each sampled shift has a recorded check.

Good practice. All crew certified, current, and checked before each shift.

Immediate fail (any one means the criterion is not met). A crew member works with an expired certificate.

Partial because. Certificates are on file but not checked before shifts.

Staff, training and documents

Documents

E-learning

42.16Driver Training Specific to Patient TransportHumanitarian settings: MediumTransition and fragile: MediumStandard: Must

Drivers of patient transport vehicles are trained specifically for patient transport, including safe driving with a patient on board.

Humanitarian settings
Medium
Transition and fragile
Medium
Standard
Must

Why it matters. General driving skill does not cover braking, turning and lifting with a patient on board, and these cause injuries.

Questions the surveyor asks

  • Is the driver trained for patient transport? Training recorded.
  • Does the training cover driving with a patient? Braking, turning and securing the patient.
  • Is the training refreshed? A date for the last refresher.

How the surveyor verifies this criterion

Sample. Ten drivers from the last 3 months.

1. Trained

Method. Check each driver file for patient-transport training.

Evidence to show. Ambulance driver (ToR).

Pass when. Every sampled driver has training recorded.

2. Covers patient on board

Method. Check the training content for patient-on-board topics.

Evidence to show. Driver safety and fatigue officer (ToR).

Pass when. The training covers patient-on-board driving.

3. Refreshed

Method. Check the last refresher date for each driver.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. Each sampled driver has a refresher in the last 2 years.

Good practice. Trained drivers, with training covering patient-on-board driving, refreshed regularly.

Immediate fail (any one means the criterion is not met). A driver has no patient-transport training.

Partial because. Drivers are trained but refreshers are overdue.

Staff, training and documents

Documents

E-learning

42.17Fatigue Management for Long-Distance TransfersHumanitarian settings: MediumTransition and fragile: MediumStandard: Must

Long-distance transfers are planned with rest breaks and shift limits, and fatigue is checked and recorded.

Humanitarian settings
Medium
Transition and fragile
Medium
Standard
Must

Why it matters. A tired driver or crew member makes errors. Long journeys increase this risk.

Questions the surveyor asks

  • Is there a shift limit for long journeys? A maximum duty time is written.
  • Are rest breaks planned? Breaks are in the plan.
  • Is fatigue checked and recorded? A check before departure.

How the surveyor verifies this criterion

Sample. Ten long-distance transfers from the last 3 months.

1. Shift limit

Method. Check the policy and the duty records for a shift limit.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Duty records stay within the limit.

2. Breaks planned

Method. Check each plan for rest breaks.

Evidence to show. Referral and evacuation route plan (FLD-PLN-001).

Pass when. Each sampled long journey plan includes breaks.

3. Fatigue checked

Method. Check the departure record for a fatigue check.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Each sampled departure has a recorded check.

Good practice. Shift limits, planned breaks and a recorded fatigue check before each long journey.

Immediate fail (any one means the criterion is not met). A long journey is driven with no limit and no breaks.

Partial because. Limits are written but breaks or checks are not recorded.

Staff, training and documents

Documents

E-learning

42.18Vehicle Maintenance Current and DocumentedHumanitarian settings: MediumTransition and fragile: MediumStandard: Must

Every patient transport vehicle has a maintenance schedule that is followed, and each service is documented.

Humanitarian settings
Medium
Transition and fragile
Medium
Standard
Must

Why it matters. A vehicle that fails on the road can leave a patient stranded or cause a crash.

Questions the surveyor asks

  • Is there a maintenance schedule? A written schedule for each vehicle.
  • Is it followed? Services happen on time.
  • Is each service documented? A service record exists.

How the surveyor verifies this criterion

Sample. All vehicles in the fleet over the last 6 months.

1. Schedule exists

Method. Check each vehicle for a written schedule.

Evidence to show. Vehicle fleet manager (ToR).

Pass when. Every vehicle has a written schedule.

2. Followed

Method. Compare service dates with the schedule.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. No sampled vehicle is overdue for service.

3. Documented

Method. Check each service for a record.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. Each service has a record.

Good practice. Written schedules, followed on time, and each service documented.

Immediate fail (any one means the criterion is not met). A vehicle is in service with no maintenance record.

Partial because. Services are documented but overdue for some vehicles.

Staff, training and documents

Documents

E-learning

42.19Medical Equipment Checked and CalibratedHumanitarian settings: MediumTransition and fragile: MediumStandard: Must

Medical equipment carried on transport is checked before each transfer and calibrated on schedule.

Humanitarian settings
Medium
Transition and fragile
Medium
Standard
Must

Why it matters. Equipment that is out of calibration gives wrong readings, which leads to wrong treatment in transit.

Questions the surveyor asks

  • Is the equipment checked before each transfer? A pre-departure check is recorded.
  • Is calibration on schedule? Calibration dates are recorded.
  • Is faulty equipment removed? Faulty items are marked out of use.

How the surveyor verifies this criterion

Sample. Ten transfers and the equipment calibration register.

1. Checked before transfer

Method. Check each transfer for a pre-departure equipment check.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. Each sampled transfer has a recorded check.

2. Calibrated on schedule

Method. Compare calibration dates with the schedule.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. No sampled item is out of calibration.

3. Faulty removed

Method. Check for faulty items marked out of use.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. Each faulty item is marked out of use.

Good practice. Equipment checked before each transfer, calibrated on time, and faulty items removed.

Immediate fail (any one means the criterion is not met). Equipment is used out of calibration.

Partial because. Equipment is checked but calibration is overdue for some items.

Staff, training and documents

Documents

E-learning

42.20Medication Storage Meets RequirementsHumanitarian settings: MustTransition and fragile: MediumStandard: Must

Medicines carried on transport are stored securely, at the right temperature, and checked before each transfer.

Humanitarian settings
Must
Transition and fragile
Medium
Standard
Must

Why it matters. Medicines stored wrongly in a vehicle lose their effect or are misused.

Questions the surveyor asks

  • Are medicines stored securely? Locked and controlled.
  • Is the temperature controlled? Temperature checked and recorded.
  • Is the stock checked before each transfer? A recorded check.

How the surveyor verifies this criterion

Sample. Ten transfers and the medicine storage records.

1. Secure

Method. Check the storage for locks and access control.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. Medicines are stored locked in every sampled vehicle.

2. Temperature controlled

Method. Check temperature records for the vehicle.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. Temperature is recorded for each sampled transfer.

3. Checked before transfer

Method. Check the record for a stock check before departure.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. Each sampled transfer has a stock check.

Good practice. Secure storage, controlled temperature and a stock check before each transfer.

Immediate fail (any one means the criterion is not met). Medicines are carried unsecured.

Partial because. Storage is secure but temperature or stock checks are not recorded.

Staff, training and documents

Documents

E-learning

42.21Vehicle Safety Equipment Present and FunctionalHumanitarian settings: MustTransition and fragile: MediumStandard: Must

Every vehicle carries the required safety equipment, such as restraints, fire extinguisher and first-aid kit, and each item is checked.

Humanitarian settings
Must
Transition and fragile
Medium
Standard
Must

Why it matters. Safety equipment that is missing or broken fails when a patient or crew member needs it.

Questions the surveyor asks

  • Is the required list carried? A written list for each vehicle.
  • Is each item functional? Checked and working.
  • Is the check recorded? A dated check record.

How the surveyor verifies this criterion

Sample. Ten vehicles and their check records.

1. List carried

Method. Check each vehicle against the required list.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. Every sampled vehicle carries the full list.

2. Functional

Method. Check each item.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. Each sampled item works.

3. Recorded

Method. Check for a dated check record.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. Each vehicle has a dated check record.

Good practice. The full list carried, every item working, and each check recorded.

Immediate fail (any one means the criterion is not met). A vehicle is in service without a required item.

Partial because. Items are present but checks are not recorded.

Staff, training and documents

Documents

E-learning

42.22Aircraft and Cabin Equipment Suitable for the PatientHumanitarian settings: MediumTransition and fragile: MediumStandard: Must

The aircraft and cabin equipment is suitable for the patient’s condition, including oxygen, monitoring and stretcher fixing.

Humanitarian settings
Medium
Transition and fragile
Medium
Standard
Must

Why it matters. Equipment that does not fit or work for the patient’s condition cannot support them in flight.

Questions the surveyor asks

  • Is the equipment matched to the patient? Written match for the patient’s needs.
  • Is the stretcher fixed securely? Checked before departure.
  • Is oxygen and monitoring on board? Checked before departure.

How the surveyor verifies this criterion

Sample. Ten air transfers from the last 3 months.

1. Matched to patient

Method. Check each record for the equipment match.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. Each sampled transfer has a recorded match.

2. Stretcher secure

Method. Check the pre-flight record for stretcher fixing.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. Each sampled flight has a recorded stretcher check.

3. Oxygen and monitoring on board

Method. Check the pre-flight record for oxygen and monitoring.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. Each sampled flight has oxygen and monitoring recorded.

Good practice. Matched equipment, a secure stretcher and oxygen and monitoring on board for each flight.

Immediate fail (any one means the criterion is not met). A flight departs with no oxygen or secure stretcher.

Partial because. Equipment is on board but not checked before departure.

Staff, training and documents

Documents

E-learning

42.23Commercial Flight: Seats, Equipment and Airline Acceptance Arranged in AdvanceHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must

When a patient travels on a commercial flight, seats, equipment and airline acceptance are arranged before the flight.

Humanitarian settings
Minimum
Transition and fragile
Medium
Standard
Must

Why it matters. Commercial flights can refuse a patient or equipment at the gate when nothing is arranged in advance.

Questions the surveyor asks

  • Is airline acceptance obtained? Written acceptance from the airline.
  • Are seats and equipment arranged? Confirmed before the day of travel.
  • Is the arrangement recorded? In the transfer record.

How the surveyor verifies this criterion

Sample. Five commercial flight transfers from the last 3 months.

1. Acceptance obtained

Method. Check each record for airline acceptance.

Evidence to show. Travel and insurance liaison officer (ToR).

Pass when. Each sampled transfer has written acceptance.

2. Seats arranged

Method. Check the booking for seats and equipment.

Evidence to show. Fitness to travel and handover to the home-country clinician (ASF tool).

Pass when. Seats and equipment are confirmed for each sampled flight.

3. Recorded

Method. Check the transfer record.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Each arrangement is recorded.

Good practice. Written airline acceptance, confirmed seats and equipment, and a record of each arrangement.

Immediate fail (any one means the criterion is not met). A patient travels with no airline acceptance.

Partial because. Acceptance is obtained but seats or equipment are not confirmed.

Staff, training and documents

Documents

E-learning

42.24Airport and Ground Segments Are Part of the Same PlanHumanitarian settings: MediumTransition and fragile: MediumStandard: Must

The airport and ground legs of a transfer are part of the same written plan, with named contacts and times.

Humanitarian settings
Medium
Transition and fragile
Medium
Standard
Must

Why it matters. When the ground and air legs are planned separately, the patient is lost in the gap between them.

Questions the surveyor asks

  • Are the ground legs in the plan? Written with the air legs.
  • Are contacts named? Each leg has a named contact.
  • Are times agreed? Pick-up and drop-off times recorded.

How the surveyor verifies this criterion

Sample. Five transfers with airport legs from the last 3 months.

1. Ground in plan

Method. Check each plan for ground legs.

Evidence to show. Referral and evacuation route plan (FLD-PLN-001).

Pass when. Every sampled plan includes the ground legs.

2. Contacts named

Method. Check each leg for a named contact.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Each leg has a named contact.

3. Times agreed

Method. Check for agreed pick-up and drop-off times.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Each sampled leg has an agreed time.

Good practice. One plan covering air and ground legs, with named contacts and agreed times.

Immediate fail (any one means the criterion is not met). Ground legs are not planned.

Partial because. Ground legs are in the plan but without contacts or times.

Staff, training and documents

Documents

E-learning

42.25Continuous Monitoring Appropriate to AcuityHumanitarian settings: MustTransition and fragile: MustStandard: Must

Patients are monitored continuously during transfer at a level appropriate to their acuity, and observations are recorded at set intervals.

Humanitarian settings
Must
Transition and fragile
Must
Standard
Must

Why it matters. A deteriorating patient in transit may not be noticed without continuous monitoring.

Questions the surveyor asks

  • Is monitoring continuous? Set by acuity.
  • Are observations recorded at intervals? A written interval is followed.
  • Is the monitor functional? Checked before departure.

How the surveyor verifies this criterion

Sample. Ten transfers from the last 3 months with their observation records.

1. Continuous

Method. Check each record for continuous monitoring.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Monitoring is recorded throughout each sampled transfer.

2. Intervals kept

Method. Check observations against the written interval.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. At least 18 of 20 observation intervals are kept.

3. Monitor checked

Method. Check the pre-departure monitor record.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. Each sampled monitor is checked before departure.

Good practice. Continuous monitoring at the right level, with observations at set intervals.

Immediate fail (any one means the criterion is not met). A patient is transported with no monitoring.

Partial because. Monitoring happens but observations are not recorded at intervals.

Staff, training and documents

Documents

E-learning

42.26Deterioration Recognition and ResponseHumanitarian settings: MustTransition and fragile: MustStandard: Must

Crew recognise deterioration early, using a written early-warning score, and respond with a written escalation plan.

Humanitarian settings
Must
Transition and fragile
Must
Standard
Must

Why it matters. Early deterioration in transit is easy to miss. A score and a plan let the crew act before the patient is in crisis.

Questions the surveyor asks

  • Is an early-warning score used? A written score.
  • Is there an escalation plan? Steps written for each score.
  • Is the response recorded? A record of what was done.

How the surveyor verifies this criterion

Sample. Ten transfers with a deterioration from the last 3 months.

1. Score used

Method. Check each record for an early-warning score.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Every sampled transfer has scores recorded.

2. Escalation plan

Method. Check the plan for escalation steps.

Evidence to show. Referral and evacuation route plan (FLD-PLN-001).

Pass when. Each sampled plan has escalation steps.

3. Response recorded

Method. Check the record for response to a deterioration.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Each sampled deterioration has a recorded response.

Good practice. A written score, escalation steps, and a recorded response to each deterioration.

Immediate fail (any one means the criterion is not met). Deterioration is not recognised or responded to.

Partial because. Scores are used but responses are not recorded.

Staff, training and documents

Documents

E-learning

42.27Cardiac Arrest and Life-Threatening Event ProtocolHumanitarian settings: MustTransition and fragile: MustStandard: Must

A written protocol for cardiac arrest and other life-threatening events in transit is known to every crew member and practised.

Humanitarian settings
Must
Transition and fragile
Must
Standard
Must

Why it matters. Cardiac arrest in a moving vehicle or aircraft needs immediate, practised action.

Questions the surveyor asks

  • Is there a written protocol? For arrest and other life-threats.
  • Do all crew know it? Tested by questions or drill.
  • Is it practised? A drill recorded in the last 12 months.

How the surveyor verifies this criterion

Sample. Crew list and drill records from the last 12 months.

1. Written protocol

Method. Check the protocol for arrest steps.

Evidence to show. Referral and evacuation route plan (FLD-PLN-001).

Pass when. The protocol covers arrest and other life-threats.

2. Crew know it

Method. Ask crew members to describe the first steps.

Evidence to show. Referral and evacuation route plan (FLD-PLN-001).

Pass when. Each sampled crew member describes the steps correctly.

3. Practised

Method. Check the drill record.

Evidence to show. Fire drill record (EMG-FRM-002).

Pass when. A drill is recorded in the last 12 months.

Good practice. A written protocol, known to all crew, practised in the last 12 months.

Immediate fail (any one means the criterion is not met). No protocol exists for arrest in transit.

Partial because. A protocol exists but is not practised.

Staff, training and documents

Documents

E-learning

42.28Diversion to the Nearest Appropriate FacilityHumanitarian settings: MediumTransition and fragile: MediumStandard: Must

A rule is written for diverting a patient to the nearest appropriate facility when the planned destination cannot take them.

Humanitarian settings
Medium
Transition and fragile
Medium
Standard
Must

Why it matters. Driving past a nearer facility to a planned one can cost a patient their life.

Questions the surveyor asks

  • Is a diversion rule written? The rule names the decision maker.
  • Is the nearest appropriate facility known? A list of options is kept.
  • Is each diversion recorded? With the reason.

How the surveyor verifies this criterion

Sample. Five diversions from the last 3 months, or the rule if none.

1. Rule written

Method. Check the rule for the decision maker.

Evidence to show. Referral and evacuation route plan (FLD-PLN-001).

Pass when. The rule names the decision maker.

2. Options known

Method. Check the list of facilities.

Evidence to show. Referral and evacuation route plan (FLD-PLN-001).

Pass when. The list includes the nearest appropriate options.

3. Recorded

Method. Check each diversion record.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Each diversion has a recorded reason.

Good practice. A written rule, a current facility list, and a recorded reason for each diversion.

Immediate fail (any one means the criterion is not met). No diversion rule exists.

Partial because. The rule exists but diversions are not recorded.

Staff, training and documents

Documents

E-learning

42.29Breakdown or Accident ContingencyHumanitarian settings: MediumTransition and fragile: MediumStandard: Must

Written contingency plans cover vehicle breakdown and accidents, with a named replacement and a recovery route.

Humanitarian settings
Medium
Transition and fragile
Medium
Standard
Must

Why it matters. A breakdown with a patient on board needs an immediate, planned response.

Questions the surveyor asks

  • Is there a contingency plan? Written for breakdown and accident.
  • Is a replacement named? A vehicle and crew on call.
  • Is it practised? A drill or record of use.

How the surveyor verifies this criterion

Sample. The contingency plan and any recorded incidents.

1. Plan written

Method. Check the plan for breakdown and accident steps.

Evidence to show. Referral and evacuation route plan (FLD-PLN-001).

Pass when. The plan covers both events.

2. Replacement named

Method. Check for a named replacement vehicle and crew.

Evidence to show. Referral and evacuation route plan (FLD-PLN-001).

Pass when. A replacement is named.

3. Practised

Method. Check for a drill or recorded use.

Evidence to show. Fire drill record (EMG-FRM-002).

Pass when. A drill or recorded use is in the last 12 months.

Good practice. Written contingency, a named replacement, and practice in the last 12 months.

Immediate fail (any one means the criterion is not met). No contingency exists.

Partial because. A plan exists but no replacement is named.

Staff, training and documents

Documents

E-learning

42.30Mass Casualty and Surge PlanHumanitarian settings: MediumTransition and fragile: MediumStandard: Must

A written mass-casualty and surge plan lets the transport service respond when many patients need transfer at once.

Humanitarian settings
Medium
Transition and fragile
Medium
Standard
Must

Why it matters. In a surge, an unplanned response leaves patients waiting and crews overloaded.

Questions the surveyor asks

  • Is there a surge plan? Written and approved.
  • Who activates it? A named role.
  • Is it tested? A drill recorded.

How the surveyor verifies this criterion

Sample. The surge plan and any drill records.

1. Plan written

Method. Check the plan for surge steps.

Evidence to show. Referral and evacuation route plan (FLD-PLN-001).

Pass when. The plan covers surge response.

2. Activation named

Method. Check for a named activation role.

Evidence to show. Referral and evacuation route plan (FLD-PLN-001).

Pass when. A named role activates the plan.

3. Tested

Method. Check for a drill record.

Evidence to show. Fire drill record (EMG-FRM-002).

Pass when. A drill is recorded in the last 12 months.

Good practice. A written surge plan, named activation, and a drill in the last 12 months.

Immediate fail (any one means the criterion is not met). No surge plan exists.

Partial because. A plan exists but has not been tested.

Staff, training and documents

Documents

E-learning

42.31Real-Time Status Communication to DispatchHumanitarian settings: MustTransition and fragile: MediumStandard: Must

Crews report status to dispatch in real time, at set points and on any change, and the reports are logged.

Humanitarian settings
Must
Transition and fragile
Medium
Standard
Must

Why it matters. Dispatch cannot coordinate a patient it cannot see. Missed reports leave the patient unsupported.

Questions the surveyor asks

  • Are status reports made? At set points.
  • Are changes reported? Immediately.
  • Are reports logged? In the dispatch log.

How the surveyor verifies this criterion

Sample. Ten transfers and the dispatch log from the last 3 months.

1. Reports made

Method. Check the dispatch log for status reports.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Reports are logged at set points in each sampled transfer.

2. Changes reported

Method. Check for logged changes in condition.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Each sampled change is reported.

3. Logged

Method. Check the log for entries.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. The log holds every report.

Good practice. Status reported at set points and on change, all logged.

Immediate fail (any one means the criterion is not met). No status reports are made.

Partial because. Reports are made but not logged.

Staff, training and documents

Documents

E-learning

42.32Structured Handover at PickupHumanitarian settings: MustTransition and fragile: MustStandard: Must

A structured handover, such as SBAR, is given at pickup from the sending clinician to the transport crew, and recorded.

Humanitarian settings
Must
Transition and fragile
Must
Standard
Must

Why it matters. A poor pickup handover loses critical information before the transfer begins.

Questions the surveyor asks

  • Is a structured handover used? A named format, such as SBAR.
  • Is it given at pickup? Before the patient leaves.
  • Is it recorded? In the transfer record.

How the surveyor verifies this criterion

Sample. Twenty pickups from the last 3 months.

1. Structured

Method. Check each handover record for the format.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Every sampled handover follows the format.

2. At pickup

Method. Check the time of handover against departure.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Every sampled handover is before departure.

3. Recorded

Method. Check the record for the handover entry.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Every sampled handover is recorded.

Good practice. A structured handover before every departure, recorded in the transfer record.

Immediate fail (any one means the criterion is not met). No handover is given at pickup.

Partial because. A handover is given but not in a structured format or not recorded.

Staff, training and documents

Documents

E-learning

42.33Structured Handover at Destination and at Every Segment ChangeHumanitarian settings: MustTransition and fragile: MustStandard: Must

A structured handover is given at the destination and at every change of segment, and each is recorded and acknowledged.

Humanitarian settings
Must
Transition and fragile
Must
Standard
Must

Why it matters. Each change of segment is a point where information is lost. A structured handover at each one keeps the patient safe.

Questions the surveyor asks

  • Is a structured handover given at each change? Including the destination.
  • Is it acknowledged? By the receiving party.
  • Is it recorded? With the name and time.

How the surveyor verifies this criterion

Sample. Twenty transfers with segment changes from the last 3 months.

1. Structured at each change

Method. Check each change for a structured handover.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Every sampled change has a structured handover.

2. Acknowledged

Method. Check for a receiver acknowledgement.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Every sampled handover is acknowledged.

3. Recorded with name and time

Method. Check the record for name and time.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Each handover has a name and time.

Good practice. A structured, acknowledged and recorded handover at each change of segment.

Immediate fail (any one means the criterion is not met). Changes of segment have no handover.

Partial because. Handovers happen but are not acknowledged or recorded.

Staff, training and documents

Documents

E-learning

42.34Written Documentation Travels With the PatientHumanitarian settings: MustTransition and fragile: MustStandard: Must

The written transfer record, clinical summary and medicine list travel with the patient at every segment.

Humanitarian settings
Must
Transition and fragile
Must
Standard
Must

Why it matters. A patient whose records do not travel arrives with no history and no plan.

Questions the surveyor asks

  • Do the records travel with the patient? In the same envelope or file.
  • Is a medicine list included? Current medicines listed.
  • Is a clinical summary included? A written summary from the sending clinician.

How the surveyor verifies this criterion

Sample. Twenty transfers from the last 3 months.

1. Records travel

Method. Check the receiving facility records for the transfer file.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. The file arrives with the patient in every sampled transfer.

2. Medicine list included

Method. Check the file for a medicine list.

Evidence to show. Minimum set-up checklist (FLD-FRM-001).

Pass when. Each sampled file has a current medicine list.

3. Clinical summary included

Method. Check the file for a summary.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. Each sampled file has a summary.

Good practice. Complete records, medicine list and summary with the patient in every transfer.

Immediate fail (any one means the criterion is not met). No written records travel with the patient.

Partial because. Records travel but the medicine list or summary is missing.

Staff, training and documents

Documents

E-learning

42.35Cross-Border Records and Data TransferHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must

Patient records for cross-border transfers are shared with the receiving country under agreed rules for consent, privacy and data protection.

Humanitarian settings
Minimum
Transition and fragile
Medium
Standard
Must

Why it matters. Records sent across borders without agreement can breach privacy law and delay care.

Questions the surveyor asks

  • Are cross-border rules agreed? Written with the receiving country.
  • Is consent covered? Consent for sharing is recorded.
  • Is data protected in transit? Secure method recorded.

How the surveyor verifies this criterion

Sample. Five cross-border transfers from the last 3 months.

1. Rules agreed

Method. Check for a written agreement for cross-border sharing.

Evidence to show. Repatriation case manager (ToR).

Pass when. A written agreement exists.

2. Consent recorded

Method. Check each record for sharing consent.

Evidence to show. Fitness to travel and handover to the home-country clinician (ASF tool).

Pass when. Consent to share is recorded in each sampled case.

3. Data protected

Method. Check the sending method.

Evidence to show. Referral and evacuation log (FLD-REG-001).

Pass when. A secure method is recorded.

Good practice. Written cross-border rules, recorded consent, and secure data transfer.

Immediate fail (any one means the criterion is not met). Records are sent across borders with no agreement.

Partial because. Rules are agreed but consent or secure transfer is not recorded.

Staff, training and documents

Documents

E-learning

    42.36Vehicle Cleaned and Disinfected Between PatientsHumanitarian settings: MustTransition and fragile: MustStandard: Must

    Vehicles are cleaned and disinfected between patients to a written standard, and each clean is recorded.

    Humanitarian settings
    Must
    Transition and fragile
    Must
    Standard
    Must

    Why it matters. A vehicle not cleaned between patients spreads infection from one patient to the next.

    Questions the surveyor asks

    • Is there a written cleaning standard? Steps and products.
    • Is it done between every patient? No patient is carried in an uncleaned vehicle.
    • Is each clean recorded? A dated record.

    How the surveyor verifies this criterion

    Sample. Twenty transfers and the cleaning records from the last 3 months.

    1. Written standard

    Method. Check the cleaning standard.

    Evidence to show. Infection prevention and control programme (IPC-POL-001).

    Pass when. A written standard exists.

    2. Done between patients

    Method. Check the cleaning record for each transfer.

    Evidence to show. Infection prevention and control programme (IPC-POL-001).

    Pass when. Each sampled transfer has a clean before the next patient.

    3. Recorded

    Method. Check each clean for a dated record.

    Evidence to show. Minimum set-up checklist (FLD-FRM-001).

    Pass when. Each clean is recorded.

    Good practice. A written standard, a clean between every patient, and each clean recorded.

    Immediate fail (any one means the criterion is not met). Vehicles are not cleaned between patients.

    Partial because. Cleaning happens but is not recorded for every transfer.

    Staff, training and documents

    Documents

    E-learning

    42.37Personal Protective Equipment Available and UsedHumanitarian settings: MustTransition and fragile: MediumStandard: Must

    PPE is available in every vehicle and used by crew according to the infection-risk assessment.

    Humanitarian settings
    Must
    Transition and fragile
    Medium
    Standard
    Must

    Why it matters. Crew who do not use PPE become infected and can spread infection to the next patient.

    Questions the surveyor asks

    • Is PPE available in each vehicle? Stocked and in date.
    • Is it used according to risk? The risk assessment decides.
    • Is use observed? Checks in the field.

    How the surveyor verifies this criterion

    Sample. Ten vehicles and a sample of crew observations.

    1. Available

    Method. Check each vehicle for PPE stock.

    Evidence to show. Infection prevention and control programme (IPC-POL-001).

    Pass when. Every sampled vehicle has PPE in stock.

    2. Used per risk

    Method. Compare use with the risk assessment.

    Evidence to show. Infection prevention and control programme (IPC-POL-001).

    Pass when. Use matches the risk assessment in the sample.

    3. Use observed

    Method. Observe crew at work and note PPE use.

    Evidence to show. Infection prevention and control programme (IPC-POL-001).

    Pass when. PPE is used correctly in the observed transfers.

    Good practice. PPE in every vehicle, used correctly according to the risk assessment.

    Immediate fail (any one means the criterion is not met). Crew work with no PPE available.

    Partial because. PPE is available but not always used.

    Staff, training and documents

    Documents

    • IPC-POL-001 Infection prevention and control programme

    E-learning

    42.38Isolation and Transmission-Risk ProtocolHumanitarian settings: MustTransition and fragile: MustStandard: Must

    A written isolation protocol for patients with a transmissible infection covers the vehicle, the crew and the receiving facility.

    Humanitarian settings
    Must
    Transition and fragile
    Must
    Standard
    Must

    Why it matters. A patient with an infection who is not isolated in transit can infect the crew and others.

    Questions the surveyor asks

    • Is there a written isolation protocol? For transmissible infection.
    • Is the receiving facility told? Before arrival.
    • Is isolation applied in transit? Recorded in the transfer.

    How the surveyor verifies this criterion

    Sample. The protocol and transfers of patients with a transmissible infection.

    1. Protocol written

    Method. Check the protocol for transmissible infection steps.

    Evidence to show. Infection prevention and control programme (IPC-POL-001).

    Pass when. The protocol covers transmissible infection.

    2. Receiving facility told

    Method. Check the record for pre-arrival notice.

    Evidence to show. Referral and evacuation log (FLD-REG-001).

    Pass when. Each sampled transfer records the notice.

    3. Applied in transit

    Method. Check the transfer record for isolation.

    Evidence to show. Infection prevention and control programme (IPC-POL-001).

    Pass when. Isolation is recorded for each sampled transfer.

    Good practice. A written protocol, the receiving facility informed, and isolation recorded in transit.

    Immediate fail (any one means the criterion is not met). No isolation protocol exists.

    Partial because. The protocol exists but isolation is not recorded in transit.

    Staff, training and documents

    Documents

    E-learning

    42.39Sharps and Biohazard Waste DisposalHumanitarian settings: MustTransition and fragile: MediumStandard: Must

    Sharps and biohazard waste from transfers are collected in puncture-proof containers and disposed of under the waste policy.

    Humanitarian settings
    Must
    Transition and fragile
    Medium
    Standard
    Must

    Why it matters. Sharps and waste left in a vehicle injure crew and the public.

    Questions the surveyor asks

    • Are sharps collected in containers? Puncture-proof and labelled.
    • Is waste disposed of under policy? Taken to the correct disposal point.
    • Is disposal recorded? A dated record.

    How the surveyor verifies this criterion

    Sample. Ten transfers and the waste records from the last 3 months.

    1. Containers used

    Method. Check each vehicle for sharps containers.

    Evidence to show. Sharps and clinical waste management (WST-SOP-001).

    Pass when. Every sampled vehicle has a container in use.

    2. Disposed under policy

    Method. Check disposal against the waste policy.

    Evidence to show. Sharps and clinical waste management (WST-SOP-001).

    Pass when. Disposal follows the policy in the sample.

    3. Recorded

    Method. Check the waste record.

    Evidence to show. Sharps and clinical waste management (WST-SOP-001).

    Pass when. Each disposal is recorded.

    Good practice. Sharps in containers, disposed of under the policy, with each disposal recorded.

    Immediate fail (any one means the criterion is not met). Sharps are left loose in a vehicle.

    Partial because. Containers are used but disposal is not recorded.

    Staff, training and documents

    Documents

    E-learning

    42.40Crew Exposure Incident ResponseHumanitarian settings: MustTransition and fragile: MustStandard: Must

    A written response to needle-stick and other exposure incidents is in place, and the crew member is treated and the incident recorded.

    Humanitarian settings
    Must
    Transition and fragile
    Must
    Standard
    Must

    Why it matters. A crew member exposed to infection needs prompt treatment and a record of the event.

    Questions the surveyor asks

    • Is there a written response? Steps for exposure.
    • Is treatment available? Post-exposure treatment arranged.
    • Is the incident recorded? A dated record.

    How the surveyor verifies this criterion

    Sample. The exposure protocol and any recorded incidents.

    1. Written response

    Method. Check the protocol for exposure steps.

    Evidence to show. Infection prevention and control programme (IPC-POL-001).

    Pass when. The protocol covers exposure.

    2. Treatment available

    Method. Check for arranged post-exposure treatment.

    Evidence to show. Infection prevention and control programme (IPC-POL-001).

    Pass when. Treatment is arranged and named.

    3. Recorded

    Method. Check the incident record.

    Evidence to show. Referral and evacuation log (FLD-REG-001).

    Pass when. Each incident is recorded.

    Good practice. A written response, arranged treatment and a record of each incident.

    Immediate fail (any one means the criterion is not met). Exposure has no written response.

    Partial because. A response exists but incidents are not recorded.

    Staff, training and documents

    Documents

    • IPC-POL-001 Infection prevention and control programme

    E-learning

    42.41Language-Appropriate Communication With the PatientHumanitarian settings: MustTransition and fragile: MediumStandard: Must

    Patients are communicated with in a language they understand, using an interpreter where needed, and the arrangement is recorded.

    Humanitarian settings
    Must
    Transition and fragile
    Medium
    Standard
    Must

    Why it matters. A patient who does not understand the transfer cannot consent or report symptoms.

    Questions the surveyor asks

    • Is an interpreter available? For languages the patient needs.
    • Is communication checked? Patient understanding confirmed.
    • Is the arrangement recorded? The language used is in the record.

    How the surveyor verifies this criterion

    Sample. Ten transfers from the last 3 months.

    1. Interpreter available

    Method. Check the service for interpreter access.

    Evidence to show. Fitness to travel and handover to the home-country clinician (ASF tool).

    Pass when. An interpreter route is written and available.

    2. Understanding confirmed

    Method. Check the record for confirmed understanding.

    Evidence to show. Referral and evacuation log (FLD-REG-001).

    Pass when. Understanding is recorded in the sample.

    3. Recorded

    Method. Check the language recorded.

    Evidence to show. Referral and evacuation log (FLD-REG-001).

    Pass when. The language used is recorded in each sampled transfer.

    Good practice. An interpreter route, confirmed understanding, and the language recorded.

    Immediate fail (any one means the criterion is not met). No interpreter route exists for a patient who needs one.

    Partial because. An interpreter route exists but its use is not recorded.

    Staff, training and documents

    Documents

    E-learning

    42.42Escort Clinicians Recognised in the Receiving CountryHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must

    Escort clinicians are recognised in the receiving country, or a licensed local clinician takes over, and the recognition is recorded.

    Humanitarian settings
    Minimum
    Transition and fragile
    Medium
    Standard
    Must

    Why it matters. An escort clinician who is not recognised may not be allowed to treat the patient on arrival.

    Questions the surveyor asks

    • Is recognition obtained? Recorded before departure.
    • Is a local clinician named if needed? A licensed clinician takes over.
    • Is the arrangement recorded? In the transfer file.

    How the surveyor verifies this criterion

    Sample. Five international transfers from the last 3 months.

    1. Recognition obtained

    Method. Check each record for recognition.

    Evidence to show. Repatriation case manager (ToR).

    Pass when. Recognition is recorded for each sampled transfer.

    2. Local clinician named

    Method. Check for a named local clinician where needed.

    Evidence to show. Repatriation case manager (ToR).

    Pass when. A named local clinician is recorded where needed.

    3. Recorded

    Method. Check the transfer file.

    Evidence to show. Referral and evacuation log (FLD-REG-001).

    Pass when. The arrangement is recorded in each file.

    Good practice. Recognition obtained before departure, a local clinician named where needed, and the arrangement recorded.

    Immediate fail (any one means the criterion is not met). An escort is sent with no recognition or local cover.

    Partial because. Recognition is obtained but not recorded.

    Staff, training and documents

    Documents

    E-learning

      42.43Import of Medicines and Equipment Across BordersHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must

      Medicines and equipment carried across borders are imported under the receiving country’s rules, with the necessary permits in advance.

      Humanitarian settings
      Minimum
      Transition and fragile
      Medium
      Standard
      Must

      Why it matters. Medicines and devices held at a border can delay treatment or be confiscated.

      Questions the surveyor asks

      • Are permits in place before travel? Written permits.
      • Are the rules of the receiving country checked? Documented check.
      • Is the list of items recorded? With quantities.

      How the surveyor verifies this criterion

      Sample. Five cross-border transfers carrying medicines or equipment from the last 3 months.

      1. Permits in place

      Method. Check each record for permits.

      Evidence to show. Repatriation case manager (ToR).

      Pass when. Permits are recorded before travel for each sampled transfer.

      2. Rules checked

      Method. Check for a documented check of the rules.

      Evidence to show. Travel and insurance liaison officer (ToR).

      Pass when. A documented check exists for each sampled transfer.

      3. Items listed

      Method. Check the list for quantities.

      Evidence to show. Minimum set-up checklist (FLD-FRM-001).

      Pass when. Each sampled transfer has a listed inventory.

      Good practice. Permits in place, rules checked and a listed inventory with quantities.

      Immediate fail (any one means the criterion is not met). Medicines are carried across a border with no permit.

      Partial because. Permits are obtained but the inventory is not listed.

      Staff, training and documents

      Documents

      E-learning

        42.44Insurance and Liability for the ChainHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must

        The insurance and liability for every segment of the transfer is confirmed in writing before departure.

        Humanitarian settings
        Minimum
        Transition and fragile
        Medium
        Standard
        Must

        Why it matters. A transfer with no confirmed insurance can leave the patient and the provider exposed to large costs.

        Questions the surveyor asks

        • Is insurance confirmed in writing? For each segment.
        • Is liability named? Which party is liable for each leg.
        • Is it confirmed before departure? Recorded.

        How the surveyor verifies this criterion

        Sample. Five transfers from the last 3 months.

        1. Insurance confirmed

        Method. Check each file for written insurance confirmation.

        Evidence to show. Travel and insurance liaison officer (ToR).

        Pass when. Written confirmation is recorded for each sampled transfer.

        2. Liability named

        Method. Check for a named liable party per leg.

        Evidence to show. Travel and insurance liaison officer (ToR).

        Pass when. Liability is named for each leg in the sample.

        3. Before departure

        Method. Check the confirmation date against departure.

        Evidence to show. Referral and evacuation log (FLD-REG-001).

        Pass when. Confirmation is dated before departure.

        Good practice. Written insurance confirmed before departure, with liability named for each leg.

        Immediate fail (any one means the criterion is not met). A transfer departs with no insurance confirmation.

        Partial because. Insurance is confirmed but liability is not named.

        Staff, training and documents

        Documents

        E-learning

          42.45Post-Incident DebriefHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must

          After every serious incident or adverse event in transit, the crew take part in a recorded debrief, and the lessons are acted on.

          Humanitarian settings
          Minimum
          Transition and fragile
          Medium
          Standard
          Must

          Why it matters. Without a debrief, the same problem happens again, and the crew carry the stress alone.

          Questions the surveyor asks

          • Is a debrief held after serious incidents? Recorded.
          • Do all crew take part? Attendance recorded.
          • Are lessons acted on? A recorded action.

          How the surveyor verifies this criterion

          Sample. Incident reports and debrief records from the last 12 months.

          1. Debrief held

          Method. Check each serious incident for a debrief.

          Evidence to show. Referral and evacuation log (FLD-REG-001).

          Pass when. A debrief is recorded for each serious incident.

          2. Crew attend

          Method. Check the attendance list.

          Evidence to show. Referral and evacuation log (FLD-REG-001).

          Pass when. All crew attend each debrief.

          3. Lessons acted on

          Method. Check for a recorded action after each debrief.

          Evidence to show. Referral and evacuation route plan (FLD-PLN-001).

          Pass when. A recorded action follows each debrief.

          Good practice. A recorded debrief after each serious incident, attended by all crew, with actions taken.

          Immediate fail (any one means the criterion is not met). No debrief after serious incidents.

          Partial because. Debriefs happen but actions are not recorded.

          Staff, training and documents

          Documents

          E-learning

          42.46Dispatch Decision Rule and Right to RefuseHumanitarian settings: MustTransition and fragile: MediumStandard: Must

          A written rule decides when a transfer is dispatched, and any crew member may refuse a transfer that is unsafe, without penalty.

          Humanitarian settings
          Must
          Transition and fragile
          Medium
          Standard
          Must

          Why it matters. Pressure to dispatch an unsafe transfer can cause harm. A written rule and a right to refuse protect the patient and crew.

          Questions the surveyor asks

          • Is there a written dispatch rule? Who decides and on what basis.
          • Can crew refuse an unsafe transfer? The right is written.
          • Is a refusal recorded and supported? Recorded without penalty.

          How the surveyor verifies this criterion

          Sample. The dispatch policy and any refusals from the last 12 months.

          1. Rule written

          Method. Check the dispatch policy for the decision rule.

          Evidence to show. Referral and evacuation route plan (FLD-PLN-001).

          Pass when. The rule names the decision maker and the basis.

          2. Right to refuse

          Method. Check the policy for the right to refuse.

          Evidence to show. Referral and evacuation route plan (FLD-PLN-001).

          Pass when. The right to refuse is written.

          3. Refusals recorded

          Method. Check the record of refusals.

          Evidence to show. Referral and evacuation log (FLD-REG-001).

          Pass when. Each refusal is recorded and no penalty is recorded.

          Good practice. A written dispatch rule, a right to refuse, and recorded refusals without penalty.

          Immediate fail (any one means the criterion is not met). No dispatch rule exists.

          Partial because. A rule exists but crew cannot refuse unsafe transfers.

          Staff, training and documents

          Documents

          E-learning

          Who is responsible for Standard 42

          Each criterion names the positions responsible for it. Every position links to its own terms of reference.

          Criterion Responsible Supports
          42.1 Each Segment Has a Named Accountable Party Transport operations manager Medical transport coordinator (booking and dispatch)
          Physician (general)
          42.2 The End of the Provider’s Responsibility Is Written Down Physician (general) Transport supervisor
          Registered nurse
          42.3 The Receiving Facility or Service Accepts the Patient Before Departure Physician (general) Medical transport coordinator (booking and dispatch)
          Medical flight dispatcher / coordinator
          42.4 The Transfer Plan Is Written Before Departure, With a Back-Up Plan Transport supervisor Physician (general)
          Dispatcher / ambulance control officer
          42.5 Pre-Transport Clinical Assessment Completed Registered nurse Physician (general)
          Triage nurse
          42.6 Transfer Level Matches Patient Need Physician (general) Triage nurse
          Transport supervisor
          42.7 Critically Ill Patients Transported With Matched Staff and Equipment Flight nurse (critical care) Flight paramedic
          Vehicle technician (ambulance and transport)
          42.8 Neonatal and Paediatric Transfers Use Specialist Arrangements Physician (general) Flight nurse (critical care)
          Transport operations manager
          42.9 Air Transport Is Planned, Authorised and Controlled Medevac operations director Pilot (air ambulance)
          Aviation safety officer
          42.10 Patient Consent Obtained and Documented Physician (general) Registered nurse
          Repatriation case manager
          42.11 Crew Scope of Practice Matches Transfer Acuity Transport supervisor Flight paramedic
          Ambulance driver
          42.12 Minimum Crew Complement Written and Applied Transport operations manager Transport supervisor
          Patient transport attendant / escort
          42.13 Escort Doctor Qualified and Credentialed for the Transfer Type Flight physician (medevac) Medevac operations director
          42.14 Escort Continuity to the Handover Point Patient transport attendant / escort Transport supervisor
          Registered nurse
          42.15 Certification Current Before Each Shift Transport supervisor Transport operations manager
          42.16 Driver Training Specific to Patient Transport Driver safety and fatigue officer Ambulance driver
          Patient transport driver (non-emergency)
          42.17 Fatigue Management for Long-Distance Transfers Driver safety and fatigue officer Transport supervisor
          Ambulance driver
          42.18 Vehicle Maintenance Current and Documented Vehicle fleet manager Vehicle technician (ambulance and transport)
          42.19 Medical Equipment Checked and Calibrated Biomedical equipment technician Vehicle technician (ambulance and transport)
          Registered nurse
          42.20 Medication Storage Meets Requirements Registered nurse Transport supervisor
          Vehicle fleet manager
          42.21 Vehicle Safety Equipment Present and Functional Vehicle fleet manager Vehicle technician (ambulance and transport)
          42.22 Aircraft and Cabin Equipment Suitable for the Patient Aircraft medical equipment technician Pilot (air ambulance)
          Medevac operations director
          42.23 Commercial Flight: Seats, Equipment and Airline Acceptance Arranged in Advance Travel and insurance liaison officer Repatriation case manager
          Medical flight dispatcher / coordinator
          42.24 Airport and Ground Segments Are Part of the Same Plan Medical flight dispatcher / coordinator Air ambulance coordinator
          Patient transport attendant / escort
          42.25 Continuous Monitoring Appropriate to Acuity Flight nurse (critical care) Flight paramedic
          Flight physician (medevac)
          42.26 Deterioration Recognition and Response Flight physician (medevac) Flight nurse (critical care)
          Flight paramedic
          42.27 Cardiac Arrest and Life-Threatening Event Protocol Flight paramedic Flight physician (medevac)
          Patient transport attendant / escort
          42.28 Diversion to the Nearest Appropriate Facility Medevac operations director Medical flight dispatcher / coordinator
          Physician (general)
          42.29 Breakdown or Accident Contingency Transport supervisor Dispatcher / ambulance control officer
          Vehicle technician (ambulance and transport)
          42.30 Mass Casualty and Surge Plan Transport operations manager Chief operating officer (COO)
          Dispatcher / ambulance control officer
          42.31 Real-Time Status Communication to Dispatch Dispatcher / ambulance control officer Transport supervisor
          Medical transport coordinator (booking and dispatch)
          42.32 Structured Handover at Pickup Registered nurse Patient transport attendant / escort
          Physician (general)
          42.33 Structured Handover at Destination and at Every Segment Change Flight physician (medevac) Flight nurse (critical care)
          Physician (general)
          42.34 Written Documentation Travels With the Patient Physician (general) Registered nurse
          Medical transport coordinator (booking and dispatch)
          42.35 Cross-Border Records and Data Transfer Repatriation case manager Travel and insurance liaison officer
          42.36 Vehicle Cleaned and Disinfected Between Patients Infection control for vehicles and cleaning crew Housekeeping supervisor
          Cleaner (hospital)
          42.37 Personal Protective Equipment Available and Used Transport supervisor Patient transport attendant / escort
          Ambulance driver
          42.38 Isolation and Transmission-Risk Protocol Physician (general) Registered nurse
          Transport supervisor
          42.39 Sharps and Biohazard Waste Disposal Transport supervisor Cleaner (hospital)
          Infection control for vehicles and cleaning crew
          42.40 Crew Exposure Incident Response Transport supervisor Physician (general)
          Registered nurse
          42.41 Language-Appropriate Communication With the Patient Patient transport attendant / escort Triage nurse
          Medical transport coordinator (booking and dispatch)
          42.42 Escort Clinicians Recognised in the Receiving Country Repatriation case manager Physician (general)
          Travel and insurance liaison officer
          42.43 Import of Medicines and Equipment Across Borders Travel and insurance liaison officer Repatriation case manager
          Chief operating officer (COO)
          42.44 Insurance and Liability for the Chain Travel and insurance liaison officer Chief operating officer (COO)
          42.45 Post-Incident Debrief Transport operations manager Transport supervisor
          Driver safety and fatigue officer
          42.46 Dispatch Decision Rule and Right to Refuse Medical transport coordinator (booking and dispatch) Medevac operations director
          Dispatcher / ambulance control officer

          Role details: reporting, supervision and training

          Training shown is the general recommendation. Role-specific training is set in the next improvement round.

          Role Reports to Supervises Recommended training
          Transport operations manager Chief operating officer (COO) Transport supervisors; medical transport coordinator Facility induction; patient transport safety and handover (general recommendation)
          Transport supervisor Transport operations manager Patient transport attendants; ambulance drivers Facility induction; patient transport safety and handover (general recommendation)
          Medevac operations director Chief operating officer (COO) Medical flight dispatcher; flight crews Facility induction; patient transport safety and handover (general recommendation)
          Medical transport coordinator (booking and dispatch) Transport operations manager None Facility induction; patient transport safety and handover (general recommendation)
          Dispatcher / ambulance control officer Transport supervisor None Facility induction; patient transport safety and handover (general recommendation)
          Flight physician (medevac) Medevac operations director Flight nurse; flight paramedic Facility induction; patient transport safety and handover (general recommendation)
          Flight nurse (critical care) Medevac operations director Flight paramedic Facility induction; patient transport safety and handover (general recommendation)
          Flight paramedic Medevac operations director None Facility induction; patient transport safety and handover (general recommendation)
          Pilot (air ambulance) Medevac operations director None Facility induction; patient transport safety and handover (general recommendation)
          Ambulance driver Transport supervisor None Facility induction; patient transport safety and handover (general recommendation)
          Patient transport attendant / escort Transport supervisor None Facility induction; patient transport safety and handover (general recommendation)
          Driver safety and fatigue officer Transport operations manager Ambulance drivers Facility induction; patient transport safety and handover (general recommendation)
          Vehicle fleet manager Chief operating officer (COO) Vehicle technicians Facility induction; patient transport safety and handover (general recommendation)
          Repatriation case manager Chief operating officer (COO) None Facility induction; patient transport safety and handover (general recommendation)
          Travel and insurance liaison officer Chief operating officer (COO) None Facility induction; patient transport safety and handover (general recommendation)
          Physician (general) Head of department (per specialty) Resident physician / house officer Facility induction; patient transport safety and handover (general recommendation)
          Registered nurse Head of nursing (per ward) None Facility induction; patient transport safety and handover (general recommendation)

          Questions and answers

          The criterion text is the authority. These answers summarise it.

          Who does Standard 42 apply to?

          Every facility or service that moves a patient between facilities or services by road, air or commercial flight. Scale the criteria to the transfers the facility makes.

          What do the colours mean for this standard?

          Red (Must) is required in every setting. Green (Medium) is required, adapted to what a humanitarian or transition setting can realistically do. Yellow (Minimum) is the lowest acceptable level in a humanitarian setting. In standard settings, every criterion is Must.

          Must every segment have a named accountable party?

          Yes. Under 42.1 each segment, including ground, air and airport legs, names one person who answers for the patient during that leg.

          Must the receiving facility accept the patient before departure?

          Yes. Under 42.3 the receiving clinician accepts the patient, and the acceptance is recorded before the transfer leaves.

          Must a back-up plan exist?

          Yes. Under 42.4 the transfer plan names a back-up destination and a back-up transport route, and the crew knows both before departure.

          Must the crew be matched to the patient?

          Yes. Under 42.7 and 42.11 the crew scope, staff and equipment match the acuity of the patient, not the availability of the vehicle.

          Must handover be structured at every change?

          Yes. Under 42.32 and 42.33 each handover is structured, recorded and acknowledged by the receiving clinician.

          Do I have to use the documents on this page?

          No. The policies, SOPs, forms and checklists are drafts to help you. Adapt them to your transport service, write your own, or upload your own. What the assessor checks is that the criterion is met and that you can show how.

          What does Under review mean for a course?

          The course is published, but its content is being checked against its title. It is listed so you can use it, but its content must be confirmed before it is relied on.

          Guidelines for this standard

          9 guidelines are held in the GMJ Guidelines Library and listed here. Each link opens the full guideline on news.gmj.ge. The complete library, grouped by standard, is at Guidelines.

          1. Prehospital emergency care – operational guidance for ambulance systems (Publisher listed on the guideline page)
          2. COVID-19 Recommendations: Prehospital Emergency Medical Services (EMS) (Publisher listed on the guideline page)
          3. Management of Inter-Hospital Transfer of Patients with COVID-19 (Publisher listed on the guideline page)
          4. Neonatal Intensive Care Transport — Service Specification (2015) (Publisher listed on the guideline page)
          5. Hospital Emergency Response Checklist (World Health Organization)
          6. EVAC-H: Evacuation of hospitals and their critical areas (Publisher listed on the guideline page)
          7. National Early Warning Score (NEWS2) (Royal College of Physicians (UK))
          8. Safe management of wastes from health-care activities, 2nd edition (2014) (World Health Organization)
          9. Interagency Emergency Health Kit (IEHK) 2024 (World Health Organization)

          Also relevant to this standard:

          References

          1. World Health Organization. Hospital Emergency Response Checklist. Geneva: WHO.
          2. World Health Organization (2014). Safe management of wastes from health-care activities, 2nd edition. Geneva: WHO.
          3. World Health Organization. Interagency Emergency Health Kit (IEHK) 2024. Geneva: WHO.
          4. Royal College of Physicians. National Early Warning Score (NEWS2). London: RCP.
          5. National Institute for Health and Care Excellence. Emergency and acute medical care in over 16s: service delivery and organisation (NG94). London: NICE.
          6. European Resuscitation Council (2025). Guidelines 2025: Paediatric Life Support. Brussels: ERC.