“Between the Flags” your thoughts?


The launch of the standardised observation chart with a colour-coded warning system, dubbed ‘Between the Flags’, was implemented at all NSW hospitals this year.

The program was dubbed “Between the Flags” because it was based on the way Surf Life Savers keep watch over us and ensure we remain within safe boundaries.
Research into health systems around the world shows that some warning signs can be recognised earlier.

Surf flags

Between the Flags supports doctors and nurses in knowing these signs, making clinical decisions on when to seek help and what sort of help is needed.
The chart dictates exactly what action staff must take when a person’s vital signs (obs) fall within the ‘yellow’ zone, which indicates early deterioration and the need for a clinical review, and the more critical ‘red’ zone, which calls for a rapid response.

The standardised system improves the way medical staff recognise and respond to patients who are clinically deteriorating.

A question regarding mandatory obs was raised by Bookworm, one of our Nurse Uncut members in our Forums:

“Since between the flags came in it is mandatory to do obs on patients at least three times a day. This is not required for aged care patients in a designated aged care unit.
I work on a Medical ward and we average half of our patients waiting for placement. A few have been with us for two years. Apparently we might get around the requirement for tds obs if the docs change the frequency and document it on the obs chart.

We have enough trouble trying to get altered calling criteria. We’ve tried to get them to document altered obs frequencies on the obs charts but then you have to get them to do it every week with the new chart.”

Has anyone else come up with a solution to this?”

What are your thoughts?

Does anyone else have trouble getting altered calling criteria?

Has anyone had trouble adjusting to “Between the Flags”?

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Image credit: Horizon 2035


This post was brought to you by the NSW Nurses’ Association.


  1. I can the see the difficulty you would be having – it’s always the case with the elderly! However, I believe that because the patients are in a general medical ward, if you do not adhere to the TDS obs, or get the doctoors to change it on the chart weekly, you would be leaving yourselves open to a lot of critisism or worse, if the patient deteriorated and no-one noticed. It is because we (nurses) seemed to have ‘lost’ our ability to detect the deteriorating patient without a prompt sheet that we are now using ‘between the flags’. The only other way you might try to change this is to implement a set of Standing Orders for each of your patients which prescribes their treatment, including obs. Personally, I wouldn’t go there. All the best.

  2. We still have not implemented it in paediatrics. It is far more complicated to design paediatric forms. We can’t use just one form due to the differing parameters for vital signs between age groups. I’ve heard that BTF was rolled out poorly in adult hospitals with little or no education before just dumping it on staff.

    Presently we are having difficulty getting education organised before it can be implemented. I think it is a good idea particularly with regard to children. When children end up in adult hospitals their care is not always optimal due to lack of paediatric medical staff. Sometimes it is the RNs who are not adept at recognising a deteriorating child early enough to prevent disaster. Kids can go downhill in minutes unlike adults. Something like a delay in reporting changes in vitals or delay in performing them due to lack of staff can mean the difference between a good or very bad outcome. I think it will be a while before we see these charts in our hospital. I think they are helpful. They can also act as a back-up for nurses trying to convince medical staff to re-examine a patient. We have all been there. This sytem would mean that the chart proves your case and if ignored by medical staff then it is on their head not yours.

  3. I am a new grad RN at a major metro referal hospital and I like BTF. I particularly like the power that it gave nurses to get action if they were concerned about their patient. Now that there is this system, I am finding that the MO’s are now more likely to come and review the patient. It also sets the chain of escalation and the registrars now have to attend red zone calls.

    I admit that it is not without it’s faults. Yes the suggested ranges do not suit everyone. One of the major issues is the altering of calling criteria – it is not hard to look at the trends and realise that a patient’s normal blood pressure is low but it is actually quite an effort to get the criteria altered to reflect this. I have been told that interns cannot change the criteria and it is quite difficult to pin down a registrar long enough to do something seemingly trivial. The actual form does not help as i find the the acute setting with QID obs, the chart only lasts a few days and then nurses have to start the process again to get the new chart changed.

    I think that senior nurses/NUMs should be able to make some alterations to the criteria and they have a large amount of clinical experience and would make the process easier.

    One concern I had was that practically none of the doctors actually had any training about this new system.

    I like the power this system gives nurses to ensure their patient gets reviewed if you are concerned and I know that in my 6 months of full time work, I have made several red zone rapid response calls and in each case this system sped up the process, ensured the patient had the care they needed and gave me the support I needed when a patient deteriorated.

    One of the nurses on the cardiac arrest team stated she hasnt been to a cardiac arrest since BTF was implemented. The system evidently does work.

  4. I think “Between the Flags” has been really good for junior staff. As a senior it can seem frustrating at times (eg: if the patient is desaturating on Room air, and falls in to the “red ” criteria, a senior would probably automatically put a Hudson Mask on and check the sats in 15 minutes before pressing the “met call’ button if the other obs are good and the patient is alert etc.)But if you strictly adhered to the protocol you would be expected to automatically press the met call button before starting intervention. However, Junior staff don’t always have empowerment, and so the response by the ICU/ met team in our hospital has improved dramatically during a “met”. It has also “enabled’ junior RMO’s, who would normally hesitate to call a “met.” themselves. (They have their own cultural issues.) Addit: there are frequent “mets’ in my unit.

  5. Getting anaesthetists to change observation parameters before a patient leaves recovery (if they deem the patient “stable” but the post-op. observations do not fit the criteria)is still problematic, and as nurses we would then have to either press a “met’ immediately that the post-op. patient hits the ward OR not accept the patient back from recovery. There is still some work to do!

  6. see, as useful as it can be as it means Drs HAVE to review the pt within a certain time frame, I feel it tries to squeeze everyone into the one size fits all approach, and leaves no room for clinical judgement. when it first came out, I found it offensive, where has the trust in nurses abilities and skills gone? now they can give anyone a colour coded obs chart and an automatic machine and just say “go for it”, without any training as to why a patient may have the obs they do, and being able to link their vital signs with the patients condition.. it irritates me that they seem to have implemented this without much consultation, there seems to be a massive lack of faith in nurses skills to pick up a deteriorating patient purely on numbers, which anyone with an automatic obs machine can do! I think it will lead to more ains as management can simply say “heres an obs chart, heres what to do if they are in the yellow band, heres what to do if they are in the red band etc etc”, and hand them an obs machine with minimal training.. and many drs seems to be reluctant to change the call criteria, even if its for a good reason.. sorry, I just don’t like BTF….

    • This is what I thought at first also, however when I thought about it a bit more I realised that there is obviously a reason why this has been introduced, and a reason why the Garling Special Commission was called. I have seen a number of incidences where human error gets in the way of clinical judgement, where seemingly senior staff have not picked up on a deterioration when they should have, and patients have suffered for it. You cannot always rely on machines to ensure patients are okay – we actually have banned automatic sphymo’s in our ward and have made everyone go back to manual ones due to the errors that were occurring. The SAGO charts can be utilised in a way that allows people to still develop their clinical judgement and critical thinking skills, it’s all about education of staff by and about questioning the observations in relation to the patient’s presentation. Do these observations reflect the clinical picture you have of the patient? Why? Why not? Is the current set of observations within the normal limits FOR THIS PATIENT? What if there is a big difference to last time? What would you do, even if they are still in the ‘white’ but there is a dramatic difference to what is normal? There is no reason why we as nurses can’t encourage ourselves and others to reflect on what the charts are telling us. They may just give us the chart but it is up to us to make the most of it.

  7. We use BTF and I agree that it does help to quickly identify the deteriorating patient. My only concern is that patients can be deteriorating and not hit the yellow or red on the charts

  8. Yes…..sometimes “the numbers” are right, but the nursing intuition is out that the patient is sick.. But, even if the intuition is right it takes a long time for some RMO’s to believe you. However, if “BTF” picks up most patients then it is probably better than what we had. Unfortunately there is no “commnets’ column of interventions for quick reference (ie: ECG’s/O2/analgesia etc.)

  9. I was under the impression that we were getting rid of automated BP machines too. The number of manual ones at my workplace has increased but we are still heavily reliant on the automatic machines. The manual BP machines are much more accurate if the cuff is fitted corrctly. You can also pick up irregular heart rates that automatic machines that can’t be picked up by automatic machines, and a lot of staff don’t manually feel the pulse unless the parameters are out. I like BTF, though am aware it has some limitations. Anything that makes recognising the deteriorating patient easier has got to be better i THINK.

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