Case Study Series - ‘Between the Flags’: A Hospital Safety Net System to Save Lives (NSW Department of Health)

8 August 2013Behavioural Insights Unit

Categorycase study

Tagscase study, health

Unexpected deaths in hospitals are often preceded by warning signs, with up to 80% of cases having indicators of deterioration in the hours or days leading up to the death.

saving lives

Issue: Unnecessary deaths can occur in hospitals when patient warning signs are missed. 

Program: ‘Between the Flags’ uses a standard set of observation charts to help recognise deteriorating patients and trigger an urgent response.

Behaviour: The charts  have red and yellow zones which enable staff to easily see whether a patient is ‘outside the flags’ and empowers them to seek help, when required.

Outcome: Since the system’s introduction, the cardio-respiratory arrest rate has declined by 38.5% in New South Wales (though this may also be attributed to other programs).

The Policy Issue

Unexpected deaths in hospitals are often preceded by warning signs, with up to 80% of cases having indicators of deterioration in the hours or days leading up to the death[1]. If these signals can be detected earlier, more lives can be saved. Despite these observations, not all hospitals have a systematic approach to the identification, review and rapid treatment of such patients.

The Policy Objective was to implement a new safety net system across hospitals in New South Wales to save more lives through early detection of deterioration. The approach is based on tracking vital sign observations such as pulse, blood pressure and respiratory rate over time by graphing them. This enables staff to more easily identify warning signs that a patient may be deteriorating, and call for help from clinicians with appropriate skill to provide rapid help. 

Behavioural Analysis of the Policy Issue

There are several factors within the environment in which doctors and nurses typically work, that can mean that a decline in a patient’s health is missed. This includes:

  • Having an incomplete picture, due to patients not being known and their illnesses only being seen through small windows of time. This leads people to rely more on heuristics, conceptual ‘rules of thumb’ which allow us to sift through information quickly and find likely answers to questions more efficiently. This can lead to poor decision making.
  • Failure to integrate available information or put the ‘pieces of the puzzle’ together. This may be compounded by poor communication of information between clinicians and may mean crucial predictors of deterioration are missed.
  • Availability bias, where doctors may estimate the likelihood that a given patient will deteriorate by recalling recent experiences with other patients, rather than relying on all the data available.
  • A diffusion of responsibility, which means staff may be less likely to take action or feel a sense of responsibility in the presence of others. Sounding the alarm about a patient may be more difficult when other staff are involved in their care.
  • Patient ownership where physicians are reluctant to ‘give up’ care to other specialists for fear of losing control over their patient.[2]

To reduce uncertainty, information should be presented in a way that is easily digestible. Highlighting key information and using colours has shown to be effective, as the limits people have in visual processing mean decision-makers must select and prioritise only the most relevant information at a given time.

The Program

‘Between the Flags’ is a system developed by a group of clinical and health systems experts brought together by Professor Cliff Hughes, the current Chief Executive Officer of the Clinical Excellence Commission, and is designed to reduce the number of serious adverse events, such as unexpected deaths and cardiac arrests. It achieves this through the development of practical and standardised tools for the recognition and response to deteriorating patients in critical conditions. In particular, the development of a standard set of observation charts for use across NSW is the foundation stone of the system.

The program’s name is inspired by the red and yellow flags found on Australian beaches, which are used to demarcate safe swimming areas. This analogy is used to demonstrate that patients are kept safe ‘between the flags’. Observations are graphed to track trends in the patient’s condition and a response is triggered if observations move into the yellow or red colour-coded zones. Implementation of ‘Between the Flags’ commenced in January 2010. It involved an extensive system-wide effort across every hospital in the state. 

The behavioural aspects of the program can be explained using the EAST framework.

EASY: The chart makes the process of patient supervision easier for staff, as it defaults the staff into certain actions when the graphed vital signs move outside the designated limits of the charts. Because there is a policy requiring them to follow through with the procedural steps, this reduces ambiguity for the staff, and means that all doctors and nurses can obtain help for their patients if they are deteriorating.

ATTRACTIVE: The program focuses on changing the design of information by making complex data easily understandable and consistent. It does this through the design of charts, providing accessible and visually engaging graphs. This is important because information that is digestible and engaging means people are less likely to rely on their own memory or mental shortcuts.

SOCIAL: The program changes the social interactions of the medical staff. Hospitals are hierarchical social environments, where it can be difficult to question the decision-making of superiors. Removing ambiguity, by making the relevant information and rules clear and consistent, can improve the social dynamic between staff.

The ‘Between the Flags’ system can change social norms, by encouraging action by the clinical team. It is made clear to all staff that no one should be criticised for sounding the alarm on a patient, giving more freedom to staff at all levels to react when concerns arise.

TIMELY: The chart allows for the timely identification of issues and the provision of treatment to deteriorating patients more quickly. Better responsiveness is made possible by having a single form, used by all clinical staff, which has everything in one place. More complex charts can add to cognitive burden and lead to delay and poorer health outcomes for patients.

Outcome and results

Since the introduction of ‘Between the Flags’, the cardio-respiratory arrest rate has declined by 38.5% in New South Wales. During the same period, the rate of calls for help for patients with late signs of deterioration (rapid response calls) increased by 24.9%, which is a positive reflection of the programs implementation and is as expected as the program matures.

In 2011 and 2012, there were 630 fewer cardio-respiratory arrests than expected based on previous experience. There is also evidence from the Quality Systems Assessment (a self-assessment survey of all clinical units) that there is strong and growing support for the program, which staff feel has improved patient safety.

The decline in the cardiac arrest rate is likely to be attributable to a number of important initiatives in New South Wales which have improved patient care, of which ‘Between the Flags’ is one. Although previous research on the introduction of simpler systems at a hospital level provided mixed results[3], the significant decline in cardiac arrests and strong current support among clinical staff means there remain grounds for optimism in the state roll out of ‘Between the Flags’, with further investigations and research into its impact  being undertaken. 

  1. DeVita, L.E., Braithwaite, R.S., Mahidhara, R. et al. (2004). Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Qual Saf Health Care, 13, pp. 251–254
  2. Hillman K, Parr M, Flabouris A, Bishop A, Stewart A. (2001a). Redefining in-hospital resuscitation: the concept of the medical emergency team. Resuscitation; 48: 105–110
  3. MERIT Study Investigators, Medical Early Response Intervention and Therapy (MERIT) Trial, The Lancet. 2005;365:2091-2097.

This case study is part of a series of behavioural insights (BI) case studies compiled by the Department of Premier and Cabinet (DPC). While DPC is working with the UK Cabinet Office to push forward the use of BI in NSW, these case studies show how the NSW Government has already successfully applied BI techniques in a number of programs.