Between The Flags Between the Flags (BTF) provides the foundation for the NSW Deteriorating Patient Safety Net System. It is a 'safety net' for patients built on the principle of early recognition of clinical deterioration based on symptoms and vital sign measurement; standardised systems then ensure any deteriorating patient receives appropriate escalation and care 1 . There are several elements to the Clinical Emergency Response System (CERS) system, which all need to be in place and functioning to provide the best possible outcomes for our patients. 1. We need to have governance - policies and guidelines for how the system must be staffed across the 24 hours and administered, how it should be led, and how it can be improved. This requires ongoing support - all the way to the top of the organisation. At Ryde we have a CERS team rostered every day and night from across the hospital, who join together to bring the equipment and expertise that a patient experiencing an emergency might need. 2. NSW has developed standard calling out criteria and facilities across the state work to promote a shared understanding across all staff as to what each category of call out means. Between the flags’ is a common way of understanding safety at the beach in Australia: and just as you should swim between the yellow and red flags – so we have electronic observation charts labelled in yellow and red to signal the safety zone for each patient. 3. CERS is a local system for escalation of care – open to staff, patients, carers, and importantly, families. In addition there is a REACH system, a specific phone number that allows anyone with concerns to secure senior help at any time that they feel things are not going well. 4. We have education for all members of staff in how this system works and their roles in it, and we monitor who is up to date in their skills to perform the necessary roles in the team. 5. Such a complex system generates a lot of data, and the Deteriorating Patient Committee is responsible for evaluating the processes and
outcomes, so we can improve and manage as the system evolves. Each year more than 84,000 Rapid Response calls alert health workers across NSW to patients who need urgent attention. As the number of Rapid responses have risen, the number of Cardiac Arrests has fallen significantly. 2 By working together, we have shown we can make a difference in the outcomes for some of our most vulnerable patients.
1. Hughes, C, Pain, C, Braithwaite, J et al., 2014, 'Between the flags: implementing a rapid response system at scale', BMJ Quality & Safety , 23(9), 714–717. 2. Ou, L, Chen, J, Hillman, K, et al., 2020, 'The effectiveness of a standardised rapid response system on the reduction of cardiopulmonary arrests and other adverse events among emergency surgical admissions', Resuscitation , 150, 162 – 169
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