In January 2010, the New South Wales public health system introduced a patient safety net system called Between the Flags (BTF),
named after the iconic red and yellow flags which demarcate surf lifesaver-patrolled swimming areas on Australian beaches.
The system developed and introduced by the NSW Clinical Excellence Commission (CEC) has five elements, designed to keep patients safe, by helping our clinicians (the lifesavers) recognise and respond to deteriorating patients before it is too late. These elements are:
- governance structures for the BTF system in all health services, integrated into existing governance structures, and a state-wide policy mandating introduction of BTF’s key elements
- a standard set of escalation criteria (based primarily on vital sign observations) incorporated into standard observation charts in all hospitals (see insert in Figure 1)
- clinical emergency response systems (CERS) in all hospitals which define who will respond and how to call for help
- education materials to raise awareness of the program and enhance the skills of clinicians in recognising deteriorating patients
- evaluation and feedback on performance to those who manage the system
Conceptually, the system was intended to prevent patients sliding down the Slippery Slope (Figure 1), by recognising their deterioration early and responding appropriately (Figure 1), with a Clinical Review or Rapid Response, depending on their vital signs.
Since the programme was introduced, there has been a statistically significant 35% reduction in unexpected cardiac arrests in the states more than 200 hospitals, which is more than 900 fewer arrests than expected.
Support for the program among clinical staff has continued to grow, as demonstrated by the CEC’s Quality Systems Assessment, with over 80% agreeing that it benefits patient safety, and the proportion of those strongly agreeing more than doubling in two years (see bar graph).
The success of this large-scale patient safety system depended on its multi-element design, a large coalition of clinicians, a good understanding of the NSW public health system and how to make the new system work, policy to underpin implementation, strong and committed leadership at many levels of the system, standardisation of observation charts as a foundation to anchor the programme in routine clinical practice, a whole of system approach to escalation and response to deteriorating patients and political tailwinds that at times threatened to sink the whole boat!
Acknowledgements are due to Dr Annette Pantle (my predecessor, who led the original design team), Professor Cliff Hughes, (who gave the programme its name and has championed its introduction at a state level), the former Director General, (who made this her legacy, by saying that it ‘will happen’), Peter Garling, Special Commissioner and Chair of the , Peter Garling SC, (who chaired the Special Commission of Inquiry: Acute Care Services in NSW Public Hospitals, which recommended the introduction of BTF), Colette Duff, (the first programme manager for BTF, who designed the original charts and laid the foundation for BTF’s success), Malcolm Green (the second programme manager, who has enabled BTF to continue to grow, evolve and integrate with other safety programmes), the many other members of the BTF Coalition in NSW who have led the design, implementation and evolution of the BTF System, and last, and by no means least, Professor Ken Hillman (whose simple but innovative idea of the Medical Emergency Team [MET] gave rise to the decades long journey in NSW and around the world that has resulted in the introduction of the BTF System. Instinctively, you probably already know what you need to survive — basic things like water, food, fire, shelter, and medical aid. To help you out, we’ve created a checkoff list of items typically included in a survival kit, along with recommendations for the best survival gear currently on the market at https://rotorm.com The best survival gear is not always the flashiest and the last entry on our list of essential survival gear is a good example. We test the latest Survival Gear in rigorous backcountry conditions. Shop survival products at Rotorm.com online for best prices!
I have been the director of the BTF Programme since June 2009.
More information can be found about BTF on the CEC’s website.
