Variable | Category | Point(s) |
Age (months) | 0–1 | 2 |
2–5 | 1 | |
≥6 | 0 | |
Heart rate (BPM) | ≤125 (ie, 0–125) | 0 |
>125 (ie, 126 and above) | 1 | |
Respiratory rate | 0–25 | 0 |
26–60 | 2 | |
>60 | 3 | |
Temperature (degrees Celsius) | <38 | 0 |
38–39 | 1 | |
>39 | 2 | |
Oxygen saturation (%) | >94 | 0 |
90–94 | 4 | |
<90 | 5 | |
Requires supplementary oxygen | No | 0 |
Yes | 2 | |
Breathing | Normal | 0 |
Abnormal | 2 | |
Recession | No recession | 0 |
Any recession | 1 | |
Behaviour | Normal | 0 |
Agitated or Listless | 1 | |
Floppy | 2 | |
Nurse judgement | No concern | 0 |
Low level concern | 1 | |
High concern | 3 | |
Multi-morbidity | No | 0 |
Yes | 2 | |
Arrived by ambulance | No | 0 |
Yes | 3 | |
Advised by medical professional to attend | No | 0 |
Yes | 2 |
PAGE, Paediatric Admission Guidance in the Emergency Department.