Triage scores for children with mental or behavioral health concerns in emergency departments were found to be inaccurate in about two-thirds of cases, according to a study published on Mar. 24 in JAMA Network Open. The research compared initial triage assessments with the actual level of care received by patients during their emergency visit.
The findings highlight potential risks to patient and staff safety when triage determinations do not accurately reflect a child's needs. The issue is particularly important as more children seek help for mental health concerns during what researchers describe as an ongoing youth mental health crisis.
Lead author Jennifer Hoffmann, MD, MS, an emergency medicine physician and researcher at Ann & Robert H. Lurie Children's Hospital of Chicago and Assistant Professor of Pediatrics at Northwestern University Feinberg School of Medicine, said: "Our study was the first to examine rates of mis-triage in pediatric emergency departments when children present for mental or behavioral health concerns." She added: "When triage determination is wrong, there might be a risk to patient and staff safety, or resources might be diverted from kids in greater need. Especially with the ongoing youth mental health crisis... our ability to accurately distinguish levels of urgency upon arrival becomes even more critical. We need to refine triage tools to be more accurate and equitable so that they will work for all children who walk through our doors seeking care."
The study analyzed data from 74,564 visits involving children aged 5-17 at one of 15 U.S. emergency departments participating in the Pediatric Emergency Care Applied Research Network Registry. Researchers focused on the Emergency Severity Index (ESI), which is used by over 90% of U.S. emergency departments.
Results showed that over-triage—assigning a higher severity score than warranted—occurred in 57% of visits, while under-triage occurred in about 8%. Over-triage was more common among younger patients and Black patients compared to White patients; under-triage was more likely among Black and Hispanic patients as well as those preferring Spanish over English.
Hoffmann advised parents: "The main message for parents is to advocate for your child. If you are worried that your child is at risk of harming themselves or others while they are waiting, tell the nurse immediately." She also said: "Underlying drivers for inequities in triage may include implicit bias... Clinicians need education on recognizing their own biases... Using automated tools or artificial intelligence (AI) ... might help achieve a more objective assessment... We also need to make interpretation services ... more readily accessible ... Ultimately, accurate and equitable triage systems are needed to match children with the right care at the right time..."
Other authors from Lurie Children's included Christina R. Rojas, MD; Aron C. Janssen, MD; and Elizabeth R. Alpern, MD.
