Table 1 Pediatric emergency triage criteria developed within our hospital

Level 1

Conditions / symptoms (critical)

Sudden cardiac arrest, respiratory arrest; airway obstruction or asphyxia; emergency endotracheal intubation/tracheotomy is required; signs of shock; sudden loss of consciousness; signs of cerebral hernia; life-threatening acute poisoning; precipitous birth (umbilical cord was not cut or Apgar score < 3); complex or multiple trauma; most severe or large burns; ocular trauma with eyeball injury

Immediate

Vital signs

Temperature (℃)

Oxygen saturation (SpO2)

AVPU (alert, verbal, pain, unresponsive) scale

≤ 35 or ≥ 41

< 90%

U

Pediatric Early Warning Score (PEWS) Score

PEWS ≥ 5

Other

The triage nurse believed that the patient was encountering a life-threatening situation and requiring emergency care

Level 2

Conditions/symptoms (high risk)

Chest distress, chest pain, heart palpitations, stable vital signs, high risk or potential risk; status epilepticus; convulsion; diabetic ketoacidosis; acute asthma with stable blood pressure and pulse rate; capillary refill time ≥ 3 s; low reaction to mental state and high level of irritability; hypersomnia (able to wake up; fall asleep without stimuli) with unstable vital signs; newborns with temperature of > 38℃; acute poisoning but does not meet level 1 criteria; sudden change in consciousness; incomplete airway obstruction; esophageal foreign body; severe anemia (no active bleeding) 30–60 g/L; abdominal pain (suspected strangulated intestinal obstruction, incarcerated hernia, intussusception, gastrointestinal perforation, or urinary tract calculi) with the pain score > 6; osteofascial compartment syndrome; active bleeding (epistaxis, hematuria, hematochezia, hemoptysis, or hematemesis) with unstable vital signs

< 10 min

Vital signs

Pulse rate (beats/min)

P > 180 (y < 3 months old);

P > 160 (3 months old ≤ y < 3 years old);

P > 140 (3 years old ≤ y < 8 years old);

P > 100 (y ≥ 8 years old)

Respiration rate (breaths/min)

R > 50 (y < 3 months old);

R > 40 (3 months old ≤ y < 3 years old);

R > 30 (3 years old ≤ y < 8 years old);

R > 20 (y ≥ 8 years old)

SpO2

90–92%

Systolic blood pressure

> 130 mmHg (≥ 5 years old) or < 75 mmHg (≥ 5 years old)

PEWS score

PEWS = 3–4

Other

The triage nurse believed that the patient was at a high-risk situation or potential risk but required no emergency care

Level 3

Conditions/symptoms

Intermittent epileptic seizures; with a history of hyperpyretic convulsion; foreign body aspiration but no breathing difficulty; dysphagia but no breathing difficulty; mental and behavior disorder; severe vomiting; symptoms of allergic reaction (obvious rashes on the skin and mucous membranes, extensive facial swelling, etc.); hypersomnia (able to wake up; fall asleep without stimuli) with stable vital signs; moderate to severe pain with any cause (score: 4–6); stable newborns; active bleeding (epistaxis, hematuria, hematochezia, hemoptysis, or hematemesis) with stable vital signs; unexplained abdominal distension with mental malaise; mucocutaneous hemorrhage/platelet ≤ 20 × 10^9/L

< 30 min

Vital signs

Pulse rate (beats/min)

88 < P < 180 (y < 3 months old);

80 < P < 160 (3 months old ≤ y < 3 years old);

64 < P < 140 (3 years old ≤ y < 8 years old);

56 < P < 120 (y ≥ 8 years old)

Respiration rate (breaths/min)

24 < R < 50 (y < 3 months old);

20 < R < 40 (3 months old ≤ y < 3 years old);

16 < R < 30 (3 years old ≤ y < 8 years old);

14 < R < 24 (y ≥ 8 years old)

PEWS score

PEWS = 1–2

Other

The pediatric patient had acute symptoms and emergency issues

Level 4

Conditions/symptoms

Vomiting or diarrhea without dehydration; Mild pain

< 240 min

PEWS score

PEWS = 0

Other

Mild or non-urgent condition