Introduction to the

Interagency Integrated
Triage Tool
Facility tool - paediatrics
AGE <12 YEARS
WHO: Clinical care of
severe acute respiratory
infections: Tool kit: Interim
guidance. 11 April 2020.
https://www.who.int/publi
cations/i/item/clinical-
care-of-severe-acute-
respiratory-infections-
tool-kit
CRITERIA CRITICAL
RED

TIME-SENSITIVE
CRITERIA
YELLOW
URGENT

CAN
PROGRESS
 High-risk vital signs
In addition to heart rate, respiratory rate, temperature, and
oxygen saturation, the AVPU is a tool to identify high-risk
patients. AVPU measures the level of consciousness of a patient.

AVPU Scale
Alert Patient is awake, responds to voice, and moves their
body. Might be confused.
Verbal Patient is not spontaneously alert but responds to verbal
stimuli.
Pain Patient responds only with application of a painful
stimulus
Unresponsive Patient is unresponsive to verbal or painful stimuli.
PATIENT CASES
 9 yr Male with fever
The patient is brought in by his father for 3 days of
fever. He has been increasingly tired and having
worsening cough and difficulty breathing. On
assessment, his chest draws in while breathing.

Is the patient unresponsive?

No
 9 yr Male with fever
The patient is brought in by his father for 3 days of
fever. He has been increasingly tired and having
worsening cough and difficulty breathing. On
assessment, his chest draws in while breathing.
Airway & Breathing:
Does the patient have central cyanosis,
stridor, or respiratory distress*?
Signs of Respiratory Distress*
 9 yr Male with fever
The patient is brought in by his father for 3 days of
fever. He has been increasingly tired and having
worsening cough and difficulty breathing. On
assessment, his chest draws in while breathing.
Airway & Breathing:
Does the patient have central cyanosis,
stridor, or respiratory distress*?
YES
 9 yr Male with fever
The patient is brought in by his father for 3 days of
fever. He has been increasingly tired and having
worsening cough and difficulty breathing. On
assessment, his chest draws in while breathing.

RED
 10 day old Male with vomiting
The patient was born without any birth
complications after a normal pregnancy. His
mother states that he vomited once earlier today
but has been feeding well otherwise.

Is the patient unresponsive?

No
 10 day old Male with vomiting
The patient was born without any birth
complications after a normal pregnancy. His
mother states that he vomited once earlier today
but has been feeding well otherwise.
Airway & Breathing:
Does the patient have central cyanosis,
stridor, or respiratory distress*?
No
 10 day old Male with vomiting
The patient was born without any birth
complications after a normal pregnancy. His
mother states that he vomited once earlier today
but has been feeding well otherwise.
Circulation:
Is there capillary refill >3 seconds; weak and fast pulse;
heavy bleeding; cold extremities; or any two of lethargy,
sunken eyes, very slow skin pinch, or drinks poorly?

No
 10 day old Male with vomiting
The patient was born without any birth
complications after a normal pregnancy. His
mother states that he vomited once earlier today
but has been feeding well otherwise.
Disability:
Does the patient have convulsions,
hypoglycaemia, or altered mental status
with stiff neck or fever?
No
 10 day old Male with vomiting
The patient was born without any birth
complications after a normal pregnancy. His
mother states that he vomited once earlier today
but has been feeding well otherwise.
Does the patient meet any other high risk
criteria?

No
 10 day old Male with vomiting
The patient was born without any birth
complications after a normal pregnancy. His
mother states that he vomited once earlier today
but has been feeding well otherwise.
Airway & Breathing:
Does the patient have any swelling or mass of the
mouth, throat or neck? Any wheezing?
No
 10 day old Male with vomiting
The patient was born without any birth
complications after a normal pregnancy. His
mother states that he vomited once earlier today
but has been feeding well otherwise.
Circulation:
Does the patient have inability to feed or drink;
vomiting everything; ongoing diarrhoea; dehydration;
or severe pallor?
No
 10 day old Male with vomiting
The patient was born without any birth
complications after a normal pregnancy. His
mother states that he vomited once earlier today
but has been feeding well otherwise.
Disability:
Is the patient restless, continuously irritable,
lethargic, or in severe pain?
No
 10 day old Male with vomiting
The patient was born without any birth
complications after a normal pregnancy. His
mother states that he vomited once earlier today
but has been feeding well otherwise.
Does the patient meet any other medium
risk criteria?

YES
 10 day old Male with vomiting
The patient was born without any birth
complications after a normal pregnancy. His
mother states that he vomited once earlier today
but has been feeding well otherwise.

YELLOW
 40 day old Female with seizure
The patient is brought in by her parents after a seizure at
home. She has had fever, cough, and runny nose for 3
days. Upon evaluation, she is crying and warm to the
touch. Her temperature is 40.5C.

Is the patient unresponsive?

No
 40 day old Female with seizure
The patient is brought in by her parents after a seizure at
home. She has had fever, cough, and runny nose for 3
days. Upon evaluation, she is crying and warm to the
touch. Her temperature is 40.5C.
Airway & Breathing:
Does the patient have central cyanosis,
stridor, or respiratory distress*?
No
 40 day old Female with seizure
The patient is brought in by her parents after a seizure at
home. She has had fever, cough, and runny nose for 3
days. Upon evaluation, she is crying and warm to the
touch. Her temperature is 40.5C.
Circulation:
Is there capillary refill >3 seconds; weak and fast pulse;
heavy bleeding; cold extremities; or any two of lethargy,
sunken eyes, very slow skin pinch, or drinks poorly?

No
 40 day old Female with seizure
The patient is brought in by her parents after a seizure at
home. She has had fever, cough, and runny nose for 3
days. Upon evaluation, she is crying and warm to the
touch. Her temperature is 40.5C.
Disability:
Does the patient have active convulsions; altered mental
status (confused, restless, continuously irritable or
lethargic) with stiff neck, hypothermia or fever; or have
hypoglycaemia?

No
 40 day old Female with seizure
The patient is brought in by her parents after a seizure at
home. She has had fever, cough, and runny nose for 3
days. Upon evaluation, she is crying and warm to the
touch. Her temperature is 40.5C.
Does the patient meet any other high risk
criteria?

YES
 40 day old Female with seizure
The patient is brought in by her parents after a seizure at
home. She has had fever, cough, and runny nose for 3
days. Upon evaluation, she is crying and warm to the
touch. Her temperature is 40.5C.
Does the patient meet any other high risk
criteria?

RED
 Resources

Guidelines, tools, and resources are available at the WHO

Emergency Care website:
https://www.who.int/health-topics/emergency-care
 Tools
Many tools for emergency care development
are available at the WHO Emergency Care
website.
○ Triage tool - for sorting patients by acuity
○ Resuscitation area designation tool - for having
a designated area for “red” patients
○ Basic Emergency Care training (BEC) - using
the ABCDE approach to assessing and
managing the patient’s complaint
○ Medical and Trauma checklists - to ensure
critical actions are not missed in the clinical
management of the seriously ill
 Acknowledgements

These slides are a collaboration of the World Health

Organization (WHO), the International Committee for the Red
Cross (ICRC), Médicins Sans Frontières (MSF), the
International Federation of the Red Cross and Red Crescent
Societies (IFRC), and the UCSF – PAHO/WHO Collaborating
Centre for Emergency and Trauma care.