CLARIPED: a new tool for risk classification in pediatric emergencies

Development steps: (i) first round of discussion among experts, first prototype; (ii) pre-test of reliability, 36 hypothetical cases; (iii) second round of discussion to perform adjustments; (iv) team training; (v) pre-test with patients in real time; (vi) third round of discussion to perform new adjustments; (vii) final pre-test of validity (20% of medical treatments in five days).

Results:

CLARIPED features five urgency categories: Red (Emergency), Orange (very urgent), Yellow (urgent), Green (little urgent) and Blue (not urgent). The first classification step includes the measurement of four vital signs (VIPE score); the second step consists in the urgency discrimination assessment. Each step results in assigning a color, selecting the most urgent one for the final classification. Each color corresponds to a maximum waiting time for medical care and referral to the most appropriate physical area for the patient's clinical condition. The interobserver agreement was substantial (kappa=0.79) and the final pre-test, with 82 medical treatments, showed good correlation between the proportion of patients in each urgency category and the number of used resources (p<0.001).

Conclusions:

CLARIPED is an objective and easy-to-use tool for simple risk classification, of which pre-tests suggest good reliability and validity. Larger-scale studies on its validity and reliability in different health contexts are ongoing and can contribute to the implementation of a nationwide pediatric risk classification system.

KEYWORDS
Triage; Emergency medical services; Pediatrics

Discriminator	Red	Orange	Yellow	Green	Blue
Maximum waiting time	Immediate	10min	30min	90min	180min
General appearance	Critical look	Looks very ill	Looks ill	Looks little ill	Very good
		Important prostration	Mild to moderate prostration	No prostration	Does not look sick
Pain (level)^a a The level of pain should be evaluated by appropriate scales for the patient's age, such as FLACC Scale or Faces Scale (<5 years) and Visual Analogic Scale (>5 years).		Strong (7-10)	Moderate (4-6)	Mild (1-3)	No pain (0)
Fever (axillary temperature)^b b Fever report (axillary temperature-AxT) measured with thermometer in the current disease (any peak in the last 24h).		Fever report ≥38.5ºC in<3 months	Fever report ≥37.5ºC in<3 months old
			Fever report ≥38.5ºC in<3 years old
			Fever report ≥39.5ºC at any age
Age			Newborn (≤28 days)
Return			1 return in<24h
			2 returns in<72h

Discriminator	Red	Orange	Yellow	Green	Blue
Level of consciousness	Unconscious (coma)	Altered (drowsiness and stupor)
Airway/breathing	Cyanotic lips	Dyspnea^a a Dyspnea: respiratory distress with presence of intercostal retractions.	Tachypnea^b b Tachypnea: increased RR according to the VIPE table (RR score>0).	Coryza and/or sneezing
Apnea	Stridor^c c Stridor: noise during inspiration with varying degrees of respiratory distress.	Hoarseness^d d Hoarseness: hoarse cry or voice or cough, without stridor or respiratory distress. in<2 years	Cough
Cardiovascular	Absent pulses	Weak pulses
Cyanotic extremities	Capillary refill>2s.
Neurological	Seizure at the time of care	Acute focal deficit	Seizure in the past 12h
	Postictal state	CBG:^e e Capillary blood glucose (CBG mg/dL): perform the test in all patients with altered level of consciousness, recent or current seizure, lethargy or previous history of diabetes. 40-60 (≤1 year) or 60-80 (>1 year)
	CBG:^e e Capillary blood glucose (CBG mg/dL): perform the test in all patients with altered level of consciousness, recent or current seizure, lethargy or previous history of diabetes. <40 (≤1 year) or<60 (>1 year)
Gastrointestinal and genitourinary		Signs of dehydration^f f Signs of dehydration: dry mouth, sunken eyes, not urinating in the last 12h, decreased skin turgor.	Current seizure or report of persistent vomiting	History of vomiting and/or diarrhea in the past 72h
	Urinary retention with palpable bladder	>5 bowel movements/day or bloody diarrhea
	Scrotal pain and/or swelling	Current and persistent abdominal pain
		Intermittent abdominal pain<2 years
Trauma	Polytrauma^g g Polytrauma: patients with traumatic injury in two or more organs.	TBI with report of loss of consciousness and/or vomiting	TBI with<12h and no report of loss of consciousness or vomiting	TBI with>12h without loss of consciousness and without vomiting
	Open fracture or deformity
	High energy mechanism^h h High energy mechanism (in the absence of information, consider any traffic accident as high energy mechanism): (a) motor vehicle accident>60km/h (belt collision); >40km/h (unbelted collision); >30km/h (motorcycle), and >10km/h (run over); (b) a fall from higher than 1m.	Suspected fracture or limb dislocation
Bleeding or woundⁱ i Wound: (a) mild: abrasions and contusions requiring no suture; (b) moderate: contusions requiring sutures, but with controlled bleeding; (c) severe: extensive contusions requiring sutures, profuse and continuous bleeding.	Uncontrolled bleeding	Profuse bleeding	Controlled moderate bleeding	Small bleeding	Minor injury without bleeding
	Extensive injury	Moderate injury	Small wound with mild bleeding
Burn^j j Burn: Rule of nines.	Face and/or inhalation	Moderate>20%	Mild<10%
	Electrical or circumferential or chemical burn
Exogenous intoxication		Present (reported)
Skin	Urticaria^l l Urticaria: unlike other skin rashes; hyperemia and elevated plaques, usually very itchy, but not always. with stridor and significant respiratory difficulty	Urticaria^l l Urticaria: unlike other skin rashes; hyperemia and elevated plaques, usually very itchy, but not always. with face edema	Extensive urticaria^l l Urticaria: unlike other skin rashes; hyperemia and elevated plaques, usually very itchy, but not always.	Rash without petechiae	Impetigo or local abscess
	Purpura^k k Purpura: presence of petechia and/or ecchymosis.	Edema without hypertension	Local urticaria
	Edema+BP>140×90	Signs of cellulite
Locomotor			Claudication+fever Acute gait disorder
Foreign body			Present
Unspecific		Unable to stand	Inconsolable crying
	Behavior change	Irritability
		Suspected abuse
Comorbidities	Diabetes, with severe hypoglycemia (CBG<20)^e e Capillary blood glucose (CBG mg/dL): perform the test in all patients with altered level of consciousness, recent or current seizure, lethargy or previous history of diabetes.	Diabetes with hypo- or hyperglycemia: CBG^e e Capillary blood glucose (CBG mg/dL): perform the test in all patients with altered level of consciousness, recent or current seizure, lethargy or previous history of diabetes. <60 or>400	Diabetes with CBG^e e Capillary blood glucose (CBG mg/dL): perform the test in all patients with altered level of consciousness, recent or current seizure, lethargy or previous history of diabetes. between 250 and 400
	Immunosuppression with fever	Neuromuscular diseases^m m Neuromuscular diseases: chronic encephalopathy, myopathy, myelomeningocele, hydrocephalus.
		Immunosuppressionⁿ n Immunosuppression: after chemotherapy, nephrotic syndrome in activity, chronic use of corticosteroids. without fever
Suspected dengue (always measure BP^o o Blood pressure (BP): Always measure in case of altered level of consciousness, recent or current seizure, suspected dengue fever, edema of the lower limbs or generalized (anasarca). lying and sitting)	Signs of shock	Presence of warning signs^p p Warning signs in dengue (presence of one or more signs): abdominal pain, persistent vomiting, respiratory distress, postural hypotension or dizziness, drowsiness, and/or irritability, spontaneous bleeding, decreased urine output, sudden drop in temperature, hypothermia, edema.	Absence of warning signs^p p Warning signs in dengue (presence of one or more signs): abdominal pain, persistent vomiting, respiratory distress, postural hypotension or dizziness, drowsiness, and/or irritability, spontaneous bleeding, decreased urine output, sudden drop in temperature, hypothermia, edema.
Signs of respiratory failure

^a
Dyspnea: respiratory distress with presence of intercostal retractions.
^b
Tachypnea: increased RR according to the VIPE table (RR score>0).
^c
Stridor: noise during inspiration with varying degrees of respiratory distress.
^d
Hoarseness: hoarse cry or voice or cough, without stridor or respiratory distress.
^e
Capillary blood glucose (CBG mg/dL): perform the test in all patients with altered level of consciousness, recent or current seizure, lethargy or previous history of diabetes.
^f
Signs of dehydration: dry mouth, sunken eyes, not urinating in the last 12h, decreased skin turgor.
^g
Polytrauma: patients with traumatic injury in two or more organs.
^h
High energy mechanism (in the absence of information, consider any traffic accident as high energy mechanism): (a) motor vehicle accident>60km/h (belt collision); >40km/h (unbelted collision); >30km/h (motorcycle), and >10km/h (run over); (b) a fall from higher than 1m.
ⁱ
Wound: (a) mild: abrasions and contusions requiring no suture; (b) moderate: contusions requiring sutures, but with controlled bleeding; (c) severe: extensive contusions requiring sutures, profuse and continuous bleeding.
^j
Burn: Rule of nines.
^k
Purpura: presence of petechia and/or ecchymosis.
^l
Urticaria: unlike other skin rashes; hyperemia and elevated plaques, usually very itchy, but not always.
^m
Neuromuscular diseases: chronic encephalopathy, myopathy, myelomeningocele, hydrocephalus.
ⁿ
Immunosuppression: after chemotherapy, nephrotic syndrome in activity, chronic use of corticosteroids.
^o
Blood pressure (BP): Always measure in case of altered level of consciousness, recent or current seizure, suspected dengue fever, edema of the lower limbs or generalized (anasarca).
^p
Warning signs in dengue (presence of one or more signs): abdominal pain, persistent vomiting, respiratory distress, postural hypotension or dizziness, drowsiness, and/or irritability, spontaneous bleeding, decreased urine output, sudden drop in temperature, hypothermia, edema.

	Frequency n (%)	0 resource n (%)	1 resource n (%)	2 resources n (%)	≥3 resources n (%)	Total n (%)	p-value^a a Chi-square test.
Blue	4 (4.2)	4 (100)	0	0	0	4 (4.9)	<0.001
Green	33 (34.8)	17 (51.5)	14 (42.4)	1 (3)	1 (3)	33 (40)
Yellow	39 (41.0)	9 (23)	17 (43.6)	12 (30.8)	1 (2.6)	39 (47.6)
Orange	6 (6.3)	0	1 (16.6)	2 (33.3)	3 (50)	6 (7.3)
Red	0	0	0	0	0	0
Missing	13 (13.7)
Total n (%)		30 (36.6)	32 (39)	15 (18.3)	5 (6)	82 (100)

Sociedade de Pediatria de São Paulo R. Maria Figueiredo, 595 - 10o andar, 04002-003 São Paulo - SP - Brasil, Tel./Fax: (11 55) 3284-0308; 3289-9809; 3284-0051 - São Paulo - SP - Brazil
E-mail: rpp@spsp.org.br

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[1] * Corresponding author. E-mail:mariaclaramb@globo.com (M.C. Magalhães-Barbosa).

Newborn to 2 months old
	4	2	1	0	2	3	4
RR	<16	16-19	20-29	30-60	61-80	81-90	>90
HR	<81	81-90	91-110	111-149	150-179	180-189	>189
SpO₂	<90	90-92	93-94	95-100

3 months to 11 months old
	4	2	1	0	2	3	4
RR	<16	16-19	20-24	25-50	51-70	71-80	>80
HR	<71	71-80	81-100	101-139	140-169	170-179	>179
SpO₂	<90	90-92	93-94	95-100

1 year to 4 years old
	4	2	1	0	2	3	4
RR	<13	13-15	16-19	20-40	41-60	61-70	>70
HR	<61	61-70	71-90	91-119	120-149	150-169	>169
SpO₂	<90	90-92	93-94	95-100

5 years to 12 years old
	4	2	1	0	2	3	4
RR	<11	11-14	15-17	18-24	25-36	37-50	>50
HR	<51	50-60	61-70	71-109	110-129	130-149	>149
SpO₂	<90	90-92	93-94	95-100

>12 years
	4	2	1	0	2	3	4
RR	<10	10	11	12-16	17-22	23-29	>29
HR	<41	41-50	51-60	61-99	100-119	120-139	>139
SpO₂	<90	90-92	93-94	95-100

Assessment of axillary temperature (regardless of age)
If HR is increased (score 2, 3 or 4) Subtract:
				0	-1	-2
AxT				36-37.4	37.5-38.5	>38.5