A new study published in JAMA Network Open found significant gaps in the accuracy and equity of emergency department triage systems for children presenting with mental or behavioral health concerns. Researchers analyzed 74,564 visits to 15 U.S. emergency departments and discovered that triage scores were inaccurate in two-thirds of the cases compared to the level of care the child actually received.
Patterns of Mis-Triage and Disparities
The study examined the Emergency Severity Index (ESI), the triage system used in over 90% of U.S. emergency departments. Over-triage—assigning a higher severity score than warranted—occurred in more than half (57%) of visits, while under-triage occurred in approximately 1 in 12 visits (8%). Racial and language disparities emerged in the data: under-triage was more likely for children who were Black, Hispanic, and those who preferred Spanish compared to English. Over-triage was more likely during visits by younger patients and Black patients compared to White patients.
Clinical Implications and Causes
The most frequently presenting primary mental health diagnosis groups were depressive disorders (25% of visits) and suicide or self-injury (23% of visits). When triage determination is wrong, there can be risks to patient and staff safety, and resources might be diverted from children in greater need. According to 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, “our study was the first to examine rates of mis-triage in pediatric emergency departments when children present for mental or behavioral health concerns.”
Recommendations for Improvement
Hoffmann identified implicit bias—unconscious stereotypes or attitudes—as a potential underlying driver of these inequities. She recommended that clinicians receive education on recognizing their own biases to avoid undue influence on care. She also suggested that automated tools or artificial intelligence (AI) to augment nurse triage assignments might help achieve more objective assessments, though these strategies require further testing. Additionally, she emphasized the need to make interpretation services in emergency departments more readily accessible to families who prefer languages other than English. Hoffmann advised parents to advocate for their child, saying: “If you are worried that your child is at risk of harming themselves or others while they are waiting, tell the nurse immediately.”
This article is an AI-assisted summary. All facts and figures are drawn from the original report: https://www.newswise.com/articles/er-triage-for-children-s-behavioral-health-too-often-wrong-shows-bias/?sc=rsla