ABSTRACT
Introduction
In pediatric emergency care, acuity assessment is required based on age‐specific physiological characteristics. However, in Japan, prehospital pediatric acuity d protocols vary regionally in the assessment tools and vital sign criteria used. This study aimed to clarify the differences in assessment tools and vital sign criteria currently used for pediatric acuity determination in Japan.
Methods
This study used data from a nationwide survey conducted in August 2024 by the Pediatric Emergency Committee, Japanese Society for Emergency Medicine, which targeted emergency medical services supervisors at all 720 fire departments across Japan regarding the presence and content of pediatric acuity determination protocols. Collected protocols were compared and analyzed for differences in assessment tools, vital sign thresholds, and age categorizations.
Results
Responses were obtained from 561 departments (77.9%). After consolidation of duplicate prefecture‐level protocols, 32 unique pediatric acuity determination protocols were included in the final analysis. Only one protocol fully adhered to the Fire and Disaster Management Agency (FDMA) framework, whereas most protocols were based on the Foundation for Ambulance Service Development (FASD) criteria. The upper and lower limits of vital signs varied, with apparent differences in younger age groups. Age categorizations ranged from three broad divisions to detailed subdivisions.
Conclusion
Japan's prehospital pediatric acuity determination shows substantial regional variability, reflected in the identification of multiple distinct protocols and limited real‐world adherence to FDMA‐based criteria. Nationwide standardization and implementation of FDMA‐based criteria should be prioritized before developing new systems, followed by validation in real‐world practice to ensure feasibility, equity, and clinical effectiveness.
Keywords: emergencies, emergency medical service, patient acuity, pediatrics, vital signs
Nationwide analysis of pediatric prehospital triage protocols revealed wide variability in assessment tools and vital sign thresholds among Japanese regions. These findings underscore the need for unified, evidence‐based criteria to improve pediatric emergency care.
1. Introduction
Accurate triage, understood as efficient assessment of patient acuity, is essential during prehospital emergency medical services upon arrival at the scene for appropriate and timely intervention [1]. For emergency medical services personnel, objective and standardized evaluation protocol and criteria enable swift and reliable decision‐making.
Various triage protocols have been developed internationally for both adults and children [2]. In Japan, structured acuity determination protocols have been promoted by the Fire and Disaster Management Agency (FDMA), in collaboration with emergency medicine specialists [3]. This protocol was created with reference to the Canadian Triage and Acuity Scale (CTAS) [4], Canadian Prehospital Acuity Scale [5], and the severity and acuity criteria formulated by the Foundation for Ambulance Service Development (FASD) [6]. It has since been adopted as the FDMA Emergency Assessment Protocol [7] and now serves as the basis for emergency acuity assessment in Japan.
In the FDMA protocol, acuity is classified into four levels: “emergent/red,” “urgent/yellow,” “less urgent/green,” and “nonurgent/white” [7]. Particularly, “red” is defined as “a condition that is already physiologically life‐threatening, or one that is deteriorating and may rapidly worsen or suddenly change.” [7] In this protocol, pediatric patients are assessed using a stepwise approach: an initial qualitative evaluation with the Pediatric Assessment Triangle (PAT) [8], followed by a quantitative assessment of vital sign criteria, and subsequent qualitative assessments of pain, bleeding tendency, mechanism of injury, and symptom‐specific observational signs. Any abnormal finding at any stage leads to classification as “red” (Figure S1).
Based on the FDMA protocols, region‐specific patient acuity determination protocols have been developed by each Medical Control Council [3]. Previous surveys indicated that many regions in Japan directly apply the pediatric FASD protocol [9], which differs from the FDMA protocol by prioritizing quantitative vital sign criteria followed by a qualitative symptom assessment (Figure S2). Additionally, given age‐related variability in pediatric vital signs, establishing age‐specific criteria is crucial [9]. However, a nationwide survey in 2013 reported substantial regional variation in the vital sign thresholds used to classify high‐acuity pediatric patients [10]. The FDMA protocol has been revised twice since 2013; it remains unclear whether these revisions have reduced regional differences in pediatric acuity assessment.
This study aimed to reexamine the protocols and vital sign criteria thresholds used to identify high‐acuity pediatric patients in emergency acuity assessment protocol across Japan and to clarify current regional variations.
2. Methods
This study was a follow‐up investigation based on a nationwide survey conducted in August 2024 by the Pediatric Emergency Committee, Japanese Society for Emergency Medicine [11]. The survey targeted emergency medical services supervisors at all 720 fire departments across Japan through the FDMA. Responses were primarily collected using a web‐based questionnaire; departments unable to complete the web survey submitted responses using an identical Excel form via email.
The questionnaire asked whether each department had established pediatric acuity determination protocol. Departments that responded affirmatively were asked to submit their documents, with follow‐up requests sent in April 2025 when the initial submission was not feasible.
From the submitted protocol, we extracted protocols used for pediatric patients. We first examined whether the protocol used to classify patients as “red” or severe (high acuity) was based on quantitative or qualitative indicators. Next, we systematically categorized the age ranges defined in the criteria and compared the patterns. Finally, we extracted the threshold values of vital signs (respiratory rate, heart rate, blood pressure, and level of consciousness), systematically categorized them, and compared their characteristics.
In this study, “protocol” refers to the structured sequence and methodology used to assess emergency acuity, including evaluation order and decision‐making processes. “Criteria” denotes the specific thresholds or reference values applied in acuity assessment, such as vital sign cutoffs and other quantitative or qualitative indicators.
3. Results
Responses were obtained from 561 fire departments (77.9%). Among them, 178 departments (31.7%) reported having pediatric acuity assessment protocols, and 167 departments indicated that relevant documents could be provided. After requesting documentation, materials were collected from 86 departments (15.3%). Because multiple departments used identical prefecture level protocols, duplicate protocols were consolidated, resulting in 32 unique pediatric acuity determination protocols being included in the final analysis (Figure 1). Fire departments providing pediatric acuity determination protocols were widely distributed across all major regions of Japan, without evidence of regional concentration (Figure S3). Furthermore, no apparent differences were observed in the urban–rural distribution between analyzed departments and those reporting the availability of pediatric‐specific acuity determination protocols (Figure S4). Therefore, the identification of 32 distinct protocols across 86 fire departments demonstrates substantial nationwide variability.
FIGURE 1.
Flow diagram of the collection of pediatric acuity assessment criteria. This diagram shows the process of selecting materials from a nationwide survey of 720 fire departments, resulting in 32 sets of criteria included in the final analysis.
Among the 32 protocols, 29 (91%) incorporated both quantitative and qualitative indicators, while one (3%) relied solely on quantitative indicators and two (6%) relied on qualitative indicators. Notably, only one protocol fully adhered to the FDMA evaluation procedure, including both the stepwise assessment sequence and vital sign thresholds. In contrast, 22 protocols were consistent with the FASD framework, and the remaining six protocols employed unique assessment sequences that did not align with FDMA or FASD. The two qualitative‐only protocols were both based on the PAT [8] (Table 1). Protocols relying exclusively on qualitative indicators generally assessed all pediatric patients as a single group. In contrast, protocols incorporating quantitative indicators established age‐dependent categories with corresponding vital sign thresholds; however, both the number of age groups and the age cutoffs defining each category varied across protocols.
TABLE 1.
Classification of pediatric emergency severity assessment protocols (n = 32).
| Type of criteria used | n (%) | Characteristics |
|---|---|---|
| Quantitative + Qualitative criteria | 29 (91%) | FDMA‐based, n = 1 (3%); FASD‐based, n = 22 (69%); Non‐FDMA/FASD (unique sequence), n = 6 (19%) |
| Quantitative criteria only | 1 (3%) | — |
| Qualitative criteria only | 2 (6%) | Both based on the Pediatric Assessment Triangle (PAT) |
Note: Among the 32 protocols analyzed, the majority (91%) combined quantitative and qualitative criteria, with most of them incorporating pediatric‐specific symptoms. A small number relied solely on quantitative (3%) or qualitative (6%) criteria, the latter exclusively using the Pediatric Assessment Triangle (PAT).
Table 2 summarizes age classifications across the included pediatric protocols. Several key differences were identified: (1) whether neonates (< 28 days) and infants (< 1 year) were categorized separately; (2) whether infancy was further subdivided by month of age; (3) variation in age thresholds distinguishing toddlers from school‐aged children; and (4) inconsistency in the upper age limit defining “pediatric” patients. In addition, five protocols defined pediatric patients as ≤ 15 years without specifying vital sign thresholds beyond the age categories used in the acuity assessment criteria.
TABLE 2.
Age group classifications in pediatric emergency acuity protocols.
| Pattern | Age range | |||||
|---|---|---|---|---|---|---|
| 1 | < 28 days | 28 days ≤, < 1 year | 1 year ≤, < 6 years | |||
| 2 | < 28 days | 28 days ≤, < 1 year | 1 year ≤, < 8 years | |||
| 3 | < 1 years | 1 year ≤, < 3 years | 3 years ≤, < 7 years | 7 years ≤, < 16 years | ||
| 4 | < 1 years | 1 year ≤, < 3 years | 3 years ≤, < 6 years | 6 years ≤, < 16 years | ||
| 5 | < 28 days | 28 days ≤, < 1 year | 1 year ≤, < 6 years | 6 years ≤, < 16 years | ||
| 6 | < 28 days | 28 days ≤, < 1 year | 1 year ≤, < 6 years | 6 years ≤, < 10 years | 10 years ≤, < 16 years | |
| 7 | < 28 days | 28 days ≤, < 1 year | 1 year ≤, < 3 years | 3 years ≤, < 6 years | 6 years ≤, < 12 years | |
| 8 | < 6 months | 6 months ≤, < 1 year | 1 year ≤, < 3 years | 3 years ≤, < 10 years | 10 ≤ | |
| 9 | < 3 months | 3 months ≤, < 6 months | 6 months ≤, < 1 year | 1 year ≤, < 3 years | 3 years ≤, < 6 years | 6 years ≤, < 10 years |
| 10 | < 3 months | 3 months ≤, < 6 months | 6 months ≤, < 1 year | 1 year ≤, < 3 years | 3 years ≤, < 6 years | 6 years ≤, < 12 years |
Note: Age group classifications varied in neonatal/infant separation, infancy subdivision, child cutoffs, and pediatric upper age limits.
Among protocols using quantitative indicators, 16 distinct patterns of vital sign threshold criteria were identified, of which 16 protocols followed the FASD‐based criteria [6]. Figure 2 illustrates variability in reference ranges for respiratory rate, heart rate, and blood pressure across different age groups. Thresholds used to define the “red” triage category varied substantially, particularly in younger age groups. Four protocols did not include blood pressure criteria.
FIGURE 2.
Comparison of vital sign thresholds by age group. Boxes represent the interquartile range (IQR), with the horizontal line indicating the median. Whiskers extend to the most extreme values within 1.5× the IQR. Closed circles indicate data points at the upper or lower extremes within the whisker range, open circles indicate outliers (values beyond 1.5× the IQR), and asterisks indicate extreme outliers (values beyond 3× the IQR). Respiratory and heart rate limits and systolic blood pressure thresholds for “red” classification in 32 protocols are shown by age. The box plots visualize linear‐protocol variability, which is particularly pronounced among younger age categories.
Regarding the assessment of consciousness levels, fire departments used either the Japan Coma Scale (JCS) or the Glasgow Coma Scale (GCS) as part of their pediatric emergency acuity criteria. Among JCS‐based criteria, 43% defined a “red” triage category at JCS ≥ 100, while 36% used JCS ≥ 30 as the threshold. In contrast, 21% of the protocols applied GCS‐based criteria, defining “red” status as GCS ≤ 8.
4. Discussion
This study clarified the diversity of pediatric acuity determination protocols in Japan. Among the 32 unique protocols analyzed, only one fully adhered to the FDMA framework, whereas most protocols were based on the FASD criteria. The presence of 32 distinct protocols across 86 fire departments demonstrates substantial nationwide variability in pediatric acuity determination practices. Consistent with the nationwide 2013 survey [9], differences were observed in age categorizations and in the vital sign thresholds for high acuity classification, particularly among younger age groups.
Among protocols relying primarily on qualitative indicators, the PAT [8] is widely used to assess initial pediatric condition without equipment. Although the PAT enables rapid evaluation, its accurate use requires training and continued practice [12]. Given the low frequency of critically ill pediatric patients (“red” cases) in Japan, maintaining sufficient proficiency may be challenging for prehospital personnel, potentially delaying appropriate responses. Moreover, children have limited physiological reserve and may deteriorate rapidly [13]. Therefore, quantitative and qualitative indicators should be combined, and clear criteria that enable prompt acuity assessment without relying on experience are required.
Both the 2013 survey [9] and the present study showed that the scale developed by the FASD [6] is widely used across Japan. Although this protocol has high sensitivity, its low specificity limits its accuracy for pediatric acuity assessment [14]. Nevertheless, it continues to be used in many regions, likely because no sufficiently validated alternative criteria have been presented. While the FDMA allows local adaptation of its Emergency Assessment Protocol, revisions to date have not addressed pediatric acuity in detail. Importantly, the FDMA protocol is based on a structured approach derived from the CTAS, which is widely used internationally, supporting the overall reliability of its framework. In protocols using criteria other than the FASD scale, the sources of threshold values were often unclear; although these values generally did not deviate substantially from existing international guidelines [13, 15, 16].
Considerable variation was also observed in pediatric age categorizations. Some protocols followed domestic definitions [17], whereas others adopted international classifications [13, 18]. Because no globally accepted standard for pediatric age categorization exists [19, 20], inconsistencies—particularly during infancy—remain common [21]. Such variation could lead to discrepancies in triage decisions at boundary ages; for example, a patient categorized as “red” (emergent) in one region may be classified as a lower‐acuity category in a neighboring region due to differing age thresholds. These inconsistencies increase the risk of under‐triage or over‐triage, with potential negative impacts on patient safety, transport decisions, and emergency medical resource allocation.
Vital sign thresholds proposed in major guidelines, including Pediatric Advanced Life Support [13], Advanced Pediatric Life Support [15], and European Pediatric Life Support [16], differ across systems. However, differences exist among these values, and issues remain regarding their uniformity [8, 9]. In particular, thresholds based on healthy children may not be fully applicable to emergency settings [22]. Although revised criteria have been proposed, external validation remains limited [16]. Consequently, pediatric vital sign criteria are still undergoing international refinement [14, 23, 24]. Establishing criteria appropriate for prehospital pediatric care in Japan therefore remains an important challenge.
Furthermore, 383 fire departments (approximately 80%) reported having no pediatric‐specific acuity assessment criteria. In these regions, triage practices remain unclear, and pediatric patients may be assessed using adult‐based criteria or rely on individual clinical judgment and on‐scene experience. Given age‐dependent physiological differences between children and adults, such practices may result in over‐triage, under‐triage, or inappropriate transport decisions. This represents not only variability in practice but also a structural gap that may compromise equity in prehospital pediatric care across regions.
Against this background, understanding how current acuity assessment criteria influence the emergency medical system is essential for establishing an approach optimal for Japan. Based on the present findings, the immediate priority should be the appropriate implementation and utilization of existing FDMA‐based protocols rather than the development of new pediatric‐specific criteria. In this context, the Pediatric Emergency Committee has already developed an educational program, Pediatric Prehospital Medical Evaluation and Care (PPMEC), designed to train prehospital providers based on the FDMA framework. Wider dissemination and systematic implementation of this program may represent a practical strategy to enhance adherence to FDMA‐based protocols in real‐world prehospital settings. We propose that pediatric emergency acuity assessment criteria in Japan be nationally standardized using the FDMA protocol as a reference framework, particularly regarding fundamental components such as vital sign thresholds and stepwise assessment procedures. Such standardization would also facilitate post hoc evaluation of protocol validity and clinical performance, which is currently difficult due to regional heterogeneity. And, comparative evaluation with international triage systems may further support refinement and alignment with global standards. Following nationwide standardization, validation in real‐world prehospital settings will be essential to assess feasibility and clinical impact. At the same time, operational decisions after acuity assessment, including transport destination and strategy, should remain adaptable to regional resource availability, especially in rural or remote areas. In summary, strengthening adherence to and nationwide standardization of the FDMA‐based framework should precede the development of new pediatric‐specific protocols. Although FASD‐based criteria are widely used, concerns regarding their specificity remain. Rather than immediately adopting alternative models or developing entirely new systems, refining thresholds within a standardized FDMA structure should be prioritized to ensure feasibility and equity. This stepwise, evidence‐based approach will enable systematic evaluation and inform future protocol refinement.
This study has several limitations. First, as it relied on a questionnaire survey of fire departments, the findings depended on response rates and submitted materials and may not fully represent nationwide practice. The fact that some departments reporting pediatric acuity assessment criteria did not submit their protocols introduces potential selection bias. Although the analyzed protocols were geographically diverse, unmeasured differences between participating and nonparticipating departments may limit the external validity of the results. Second, some triage criteria lacked information on their sources or revision dates, making it difficult to assess their reliability or confirm that the most recent versions were analyzed. Third, this study focused on structural comparison of criteria and did not evaluate the diagnostic performance or clinical validity of individual vital sign thresholds in real‐world practice. Consequently, triage practices and potential risks in settings without dedicated pediatric protocols could not be evaluated, which may limit generalizability. Further studies are needed to clarify real‐world practices in such settings and their impact on patient outcomes.
5. Conclusion
Japan's prehospital pediatric triage currently shows substantial regional variability, as demonstrated by the wide diversity of protocols identified across participating fire departments, along with limited real‐world adherence to FDMA‐based criteria. Nationwide standardization and implementation of FDMA‐based criteria should be prioritized before developing new systems, followed by validation in real‐world practice to ensure feasibility, equity, and clinical effectiveness.
Funding
This work was supported by ZENKYOREN.
Ethics Statement
The authors have nothing to report.
Consent
The authors have nothing to report.
Conflicts of Interest
The authors S.M. and C.T. received research funding from ZENKYOREN, the National Mutual Insurance Federation of Agricultural Cooperatives of Japan. All other authors declare no conflicts of interest for this article.
Supporting information
Figure S1: Flowchart of the Fire and Disaster Management Agency (FDMA).
Figure S2: Flowchart of the Foundation for Ambulance Service Development (FASD).
Figure S3: Regional distribution of pediatric acuity determination protocol across Japan.
Figure S4: Distribution of departments with protocols and provided protocols by city type.
Acknowledgements
We are grateful to all the fire departments nationwide, as well as the members of the Pediatric Emergency Committee and the Pediatric Prehospital Care Training Course Working Group, for their valuable cooperation and support.
Data Availability Statement
Data supporting the findings of this study are available upon request from the corresponding authors.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Figure S1: Flowchart of the Fire and Disaster Management Agency (FDMA).
Figure S2: Flowchart of the Foundation for Ambulance Service Development (FASD).
Figure S3: Regional distribution of pediatric acuity determination protocol across Japan.
Figure S4: Distribution of departments with protocols and provided protocols by city type.
Data Availability Statement
Data supporting the findings of this study are available upon request from the corresponding authors.