Between the Flags

Clinical Emergency Response Systems (CERS)

Clinical Emergency Response Systems (CERS) refers to a health service/facility's response to a deteriorating patient within its care. CERS are developed and tailored to the health service/facility's needs and resources. The main components of this system of escalation include:

  • A Clinical Review process that has the capacity to respond within 30 minutes to a breach in Clinical Review criteria
  • A Rapid Response process that is immediately available in response to a breach in the Rapid Response criteria
  • Necessary equipment is available to perform advanced resuscitation
  • An escalation process for transferring patients that require a higher-order of care to a facility that can provide it.

Minimum standards for Clinical Emergency Response Systems are detailed in the NSW Health policy PD2013_049 Recognition and Management of Patients who are Clinical Deteriorating.

Clinical judgement remains paramount to the care of the patient at all times. The Between the Flags program is designed to give clinicians confidence to call for help when it is required. Clinical judgement and advice by senior staff (such as the nurse-in-charge) regarding the patient assessment and  activation of a Clinical Review is recommended. A patient may have an observation within the Yellow Zone which doesn't reflect deterioration in clinical condition and therefore doesn't require the activation of the CERS within the facility. Similarly, a clinician may be worried about a patient who has  observations that are "between the flags" and not breaching any Yellow or Red Zone criteria. At any time the clinician can call a Clinical Review or Rapid Response.

When responding to the activation of a CERS, comprehensive documentation in the patient's medical records is essential and should include:

  • Date and time
  • Name of staff notified
  • Reason for call
  • Time that the patient was seen for the Clinical Review or Rapid Response
  • Treatment and action arising from the Clinical Review of Rapid Response
  • Outcomes following treatment/action.

CERS Assist

NSW Ambulance Service has developed CERS Assist. This aims to provide urgent additional clinical assistance in response to a rapidly deteriorating patient in a public health care facility. CERS Assist originated from the identification of the ambulance service as an agency that may have the capacity to provide additional assistance in response to clinical emergency, especially within rural and remote locations across NSW.

CERS Assist

Documentation Tools

Individual facilities and local health districts within NSW Health have developed tools to support the documentation of a Clinical Review and Rapid Response. The CEC in collaborative with LHD clinical representatives have developed tools to support documentation and data collection.