Between the flags: implementing a safety-net system at scale to recognise and manage deteriorating patients in the New South Wales Public Health System.

Quality Problem: In 2005, the Clinical Excellence Commission (CEC) found that unrecognised patient deterioration remained an important problem in New South Wales (NSW) public hospitals.

Initial Assessment: The challenge was to design and implement an effective and sustainable safety-net system in all 225 NSW public hospitals.

Designing A Solution: The CEC's system was designed in collaboration with a broad coalition of partners, including clinicians, managers, system administrators and collaborating agencies. A five-element system comprising governance, standard calling criteria in standard observation charts, two-level clinical emergency response systems (CERS) in each facility, an education programme and evaluation, was designed for state-wide implementation. This system was called 'Between the Flags' (BTF).

Implementation: Implementation was led by the CEC on behalf of a NSW coalition, and commenced in January 2010 with the implementation of the Standard Adult General Observation Chart, awareness training for all staff and a CERS in each facility.

Evaluation: Since the introduction of BTF, the cardiac arrest rate has declined by 42% (P < 0.05) and the Rapid Response rate has increased by 135.9% (P < 0.05) in NSW. The strength of staff support for BTF has grown with the proportion of respondents strongly agreeing that BTF has benefitted patient safety more than doubling from 21% to 44%, and overall agreement rising from 68% to 82% between 2010 and 2012.

Lessons Learned: Key success factors are a focus on governance, standardisation of observation charts and striking the right balance between a rule-based approach and individual clinical judgement.