Paediatric Quality Program

Between the Flags

The Between the Flags (BTF) system is a 'safety net' for all patients, including children and young people, who are cared for in NSW public hospitals and health care facilities. It is designed to protect these patients from deteriorating undetected and to ensure they receive appropriate care if they do.


Standard Paediatric General Observation Charts (SPOC)

Paediatric Emergency Observation Charts (ED SPOC)

UPDATED April 2015


In some cases, babies and children who deteriorate may require transfer to a facility with paediatric specific expertise. There must be a paediatric-specific Clinical Emergency Response System (CERS) and escalation response relevant to all units and departments within any facility where children are cared for, or may present.

The NSW Health Paediatric CERS and Escalation Matrix describes the response and escalation process for all facilities (medical role delineation 1-6). Local CERS and Escalation algorithms must be developed based on this matrix and be clearly displayed in all clinical units.

Further information on paediatric escalation beyond facility and transfer processes is available in the NSW Health Policy PD2013_049 - Recognition and Management of Patients who are Clinically Deteriorating

  • Section - 4.3.1 Paediatric escalation beyond facility and transfer processes
  • Section - 8.1 Guide to Paediatric CERS and Beyond Facility Escalation Documentation
  • Section - 8.2 NSW Health Between the Flags Paediatric CERS and Escalation Matrix


These education resources aim to provide health care practitioners with the knowledge, skills and understanding to recognise and respond to early and late warning signs of clinical deterioration in infants and children. They are aimed at assisting clinicians in developing a systematic approach to ensure appropriate assessment and timely intervention and escalation.

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Between the Flags (BTF)
Paediatric Quality Program