Between The Flags

Allowah uses the Clinical Excellence Commission’s (CEC) Between the Flags (BTF) system to activate the CERS and intervene in the process of patient deterioration with two key interventions – Clinical Review (Yellow Zone) and Rapid Response (Red Zone).

Standard Observation Charts

Use the buttons below to access the correct chart depending on the child’s age.

Clinical Emergency Response System

The Between The Flags [BTF] system activates the Clinical Emergency Response System [CERS] based upon the vital and visual observations of the child according to the NSW Health Standard Paediatric Observation Chart [SPOC].

Standard Observation Charts incorporate three colour coded zones:

BLUE ZONE

Increased patient observation and surveillance is required.

YELLOW ZONE

Early warning signs of deterioration and the criteria for which a Clinical Review (or other CERS) call may be required.

RED ZONE

Late warning signs of deterioration and criteria for which a Rapid Response call is required.

CERS

BLUE

ZONE

ACTION

If a patient has any one BLUE ZONE CRITERIA, their observations are repeated in 1hr or more frequently as deemed clinically appropriate
You MUST initiate appropriate clinical care – manage anxiety, pain and review oxygenation in consultation with the RN in Charge.
You may call for a Clinical Review or Rapid Response at any time if worried about a patient or are unsure whether to call by immediately notifying the RN in Charge or activating the emergency buzzer.

CERS

YELLOW

ZONE

Clinical Review

ADDITIONAL CRITERIA

Increasing oxygen requirement
Poor peripheral circulation
Greater than expected fluid loss
Reduced urine output or anuria (<1 ml/kg/hr)
BGL 2-3mmol/L
New, increasing or uncontrolled pain

ACTION

If a patient has any one YELLOW ZONE CRITERIA OR ADDITIONAL CRITERIA, the RN in Charge is notified immediately to determine if Clinical Review and escalation of care is needed – Rapid Response.
Interventions MUST be put in place to reverse / halt deterioration.
Repeat observations within 30 minutes and increase frequency as indicated by the child’s condition.
RN in Charge must contact the Doctor on call within 30 minutes of yellow zone observations being attended.
Notify the DON when appropriate to do so.
If you are unable to contact the Doctor within 30 minutes of yellow zone observations being attended you MUST ACTIVATE A RAPID RESPONSE.
If the patient’s observations enter the red zone while you are waiting for a Clinical Review, you MUST ACTIVATE A RAPID RESPONSE (see below).
The patient’s family is to be informed by the RN in Charge or DON.

CERS

RED

ZONE

Rapid Response

ADDITIONAL CRITERIA

New onset of stridor
Respiratory arrest
Cardiac arrest or circulatory collapse
Significant bleeding
Sudden decrease in level of consciousness of ≥2 points on GCS
BGL < 2mmol/L or symptomatic
New or prolonged seizure activity
3 or more simultaneous Yellow Zone observations
Deterioration not reversed within 1 hour of Clinical Review
Patient deteriorates further before, during or after Clinical Review
Serious concern by any staff or family member

ACTION

If a patient has any one RED ZONE CRITERIA OR ADDITIONAL CRITERIA, the RN in Charge is notified immediately and a RAPID RESPONSE must be activated. Initiate appropriate care such as CPR.
Obtain help immediately:

1. 1. 1. Call an ambulance (call 000) and
    2. Call the Doctor on call.

Notify the DON when appropriate to do so.
Repeat and increase frequency of observations as indicated by the patient’s condition.
Refer to the patient’s Advanced Care Directives, Resuscitation Plans, NSW Ambulance Form, Authorised Paediatric Palliative Care Plan, Paediatric/Adult or Palliative Care Plan and Allowah MR32 Clinical Deterioration Consent Form as applicable.
The patient’s family is to be informed by the RN in Charge or DON.

CERS

Transfer to other levels of care

ADDITIONAL CRITERIA

Decision to transfer the patient to another facility for care is made by the RN in Charge in consultation with the VMO and is based on the observations.
Patient transfer using supported non-emergency transport.
If patient transfer is considered to be non-urgent and patient is to be transferred using supported non-emergency transport, the VMO on call or the DON must certify that the patient does not require an emergency ambulance service and has a low risk of deterioration during the transfer.

ACTION

The decision to transfer a patient is made in consultation with VMO.
Observations must be conducted prior to transfer.
Handover of patient to other level of care, NSW Ambulance, Emergency Department of admitting hospital, including notification of any Resuscitation Plan and a Copy of Transfer form (Form MR32 for NDIS children), medication chart, intervention pathway, care plan and any Resuscitation Plan to be attached to discharge summary and given to paramedic or other care provider.