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Posted on 13 Apr 2021
Incident response/review
Patient experience and outcomes
Quality/safety improvement


As there is no public announcement system at Benalla Health, the current alert system involves activation of an ‘emergency’ call buzzer for all levels of deterioration. Therefore, the current alert system cannot differentiate between a code blue and a rapid response call. This results in a large/unnecessary amount of staff presenting to all levels of deterioration and general practitioners being called away from their clinics inappropriately.


To decrease the urgent care centre ‘emergency buzzer’ alert by 20 per cent by June 2020.

Due to the high-risk nature of the change ideas, the team successfully conducted multiple simulation sessions to test the feasibility of their ‘new way’ of activating a rapid response call before testing began in the clinical area.

Change ideas tested

  • Telephone activation for rapid response calls.
  • Increase support from local nurse unit managers and hospital coordinators.
  • Clarity of roles and responsibilities for the rapid response team.
  • Greater liaising with the on-call GPs.
  • Regular rapid response education sessions using simulation.


Barwin Health - Recognition of and response to the deteriorating patient

  • Introduction and standardisation of new rapid response call activation via a phone call. Code blue activation remains via the emergency buzzer.
  • Members of the rapid response team are identified each shift and are given clear roles and responsibilities – no longer large numbers of staff attending each rapid response call.
  • Clear guidelines have been introduced for handover of the deterioration to the GP.
  • Every Tuesday morning the health service conduct an in-situ rapid response simulation, rotating staff each time so that everyone gets experience.

Anecdotally there has been a significant increase in staff satisfaction and engagement with both the rapid response system and the health service.

Spread plan

The team plans to fully implement the new rapid response system into the urgent care centre and across all other areas of their health service.

Sustainability plan

The team plans to standardise documents and policies to reflect the change. Weekly simulations will continue every Tuesday and expand to include other personal.

For more information contact: Cara Hammond, After hours hospital coordinator,

This case study is taken from Safer Care Victoria's Improving the recognition of and response to the deteriorating patient - change package document. More case studies from participating health services can be found from page 20.