Evaluating the Between The Flags (BTF) Program: A NSW Initiative

The Between The Flags (BTF) program is a safety net initiative implemented in New South Wales (NSW) public healthcare facilities to protect patients from undetected deterioration and ensure timely and appropriate care. Originating from the preventable death of a young patient, Vanessa Anderson, BTF aims to recognize and respond to deteriorating patients, save lives, reduce preventable deaths, and prevent serious adverse events. The program's elements include governance structures, standard calling criteria, Clinical Emergency Response Systems (CERS), education tiers, and key performance indicators (KPIs). Governance ensures support and sustainability, while standard observation charts help clinicians identify vital signs indicating deterioration. CERS involves afferent and efferent limbs for triggering and responding to emergencies. Education addresses skill gaps in identifying and responding to deterioration. KPIs, such as rapid response calls, are used for evaluation. The program's success relies on early detection and coordinated responses, highlighting the need for continuous education and skill development among healthcare providers, especially junior medical staff. The BTF program serves as a crucial early warning system, tracking physiological markers to improve patient outcomes and reduce preventable deaths in NSW hospitals.

Between The Flags
Introduction
BTF is a “safety net” for patients in NWS public healthcare facilities. The program is
created to protect patients from undiscovered deterioration and to make sure patients get
proper care if their condition worsens (Clinical Excellence Commission, 2018). Through
this program, early stage of deterioration or serious illness is identified, and the patient is
transferred to appropriate care. The initial plan was to implement BFT in about 200
healthcare facilities across the state (Clinical Excellence Commission, 2018). The
program was proposed following the death of Vanessa Anderson, a 16-year-old girl
(Williams, Armitage, Milson-Hawke & Thomson, 2014). Vanessa’s death could have
been prevented if there was a fast detection program for deterioration. Recent statists
support the implementation of BTF program. Between 2014 and 2015, there were about
76,856 deaths in Australian hospitals. About 58% of these deaths were in emergency
admissions, and 21% were elective admissions as shown in figure 1 (AIHW, 2017).
Aims
• To recognize and respond to deteriorating patients
• To save a life by identifying early signs of deteriorating
• To reduce the number of potentially preventable deaths
• To prevent serious adverse events in patients in NSW public
healthcare facilities
• To respond to the clinical review and rapid response
Strategies
• There is a governance structure to ensure adequate support as well as
sustainability of BTF. The governance structure consists of medical
healthcare professionals and program sponsors.
• The second strategy is the determination of the situations that require
an immediate response. Charts are used to help nurses to determine
the early stage and late stage of deteriorating. This strategy
recognizes that at the early stage of deteriorating, patients require a
fast, coordinated and specific response to save lives (Clinical
Excellence Commission, 2018).
• Another strategy is the establishment of response criteria and who
should respond. The response criterion is a well-outlined procedure
of how healthcare professionals should react when a patient is
deteriorating.
• BTF further uses education strategy as an essential strategy to
accomplish its mission of saving lives. Education addresses the gap
in skills and knowledge concerning the identification and response to
patient deteriorating.
• The last strategy is the use of key performance indicators (KPIs).
Conclusion
Preventable deaths usually occur in public hospitals due to the lack of
effective criteria of recognizing patient deterioration. BTF can be
compared to early warning programs that track different physiological
markers including temperature, respiratory rate, and heart rate. A review
of BTF implies that it is beneficial because it saves lives by recognizing
early signs of patient deterioration and initiating an appropriate response.
Health care providers, mainly junior medical staff require more
knowledge and skills on how to apply BTF.
References
AIHW. (2017). Deaths in Australian hospitals 2014-15. Web Report. Retrieved from https://www.aihw.gov.au/reports/hospitals/deaths-in-
australian-hospitals-2014-15/contents/summary/how-urgently-was-care-required
Clinical Excellence Commission. (2018). Between The Flags. Retrieved from http://www.cec.health.nsw.gov.au/patient-safety-programs/adult-
patient-safety/between-the-flags
Green, M. (2013). Between the Flags Program: Interim Evaluation Report. Clinical Excellence Commission.
Williams, A. K., Armitage, D., Milson-Hawke, S., & Thomson, N. (2014). Evaluating the Effectiveness of DETECT Education on Nursing
Practice. HNE Handover: For Nurses and Midwives, 7(1), 1-3.
Elements of the program
1. Governance: Clinical staff asserts that governance leads to the success of the BTF
program. The health service is in charge of establishing the administrative structure to
monitor the implementation of BTF (Green, 2013). BTF success can be attributed to
the existing governance structure, which includes;
Executive sponsors, clinical governance units , BTF program managers, and clinical
leads .
2. Standard calling criteria: Standard Observation Charts guide healthcare
providers. Through the charts, clinicians can identify vital signs and determine when
a client is deteriorating. The charts use red to show late signs and yellow for early
symptoms of deterioration. The charts are for adults, newborns, and maternity (Green,
2013).
3. Clinical Emergency Response Systems (CERS): This element has two
components including afferent limb and efferent limb. The afferent limb is the
procedure which triggers team responses while efferent limb consists the healthcare
providers who respond to an emergency (Green, 2013).
4. Education: An education plan for BTF was launched in 2010, and it consists of
three tiers.
• Tier 1 – Online awareness program
• Tier 2 – DETECT/DETECT junior education to educate clinical staff on how to
identify and respond to the deterioration
• Tier 3 – More specific education is offered to inform nurses how to respond in the
Red Zone (Green, 2013).
5. Evaluation: The key performance indicators (KPIs) are rapid response calls/1000
responses and cardiorespiratory arrest calls/100 separations (Green, 2013). The KPIs
are shown in figure 4.
Figure 1: Deaths in public hospitals
Source: (AIHW, 2017)
Figure 2: The Slippery Slope – Concept of BTF
Source: (Clinical Excellence Commission, 2018)
Figure 3: BTF Identifies Early Signs of Deterioration
Source: (Clinical Excellence Commission, 2018)
Figure 4: KIPs of BTF
Source: (Green, 2013)