Table 5 Pediatric emergency triage criteria established in this study

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; Precipitously 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

PEWS score

PEWS ≥ 5

Other

The triage nurse believed that the patients 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 epilepsy; 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 patients 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