ER triage for children’s behavioral health too often wrong, shows bias
Parents advised to tell the nurse immediately if they are worried their child is at risk for harming themselves or others while waiting
In emergency medicine, triage differentiates patients who require immediate attention from those who can safely wait for care. When it comes to children’s mental or behavioral health, however, triage scores were found to be inaccurate in two-thirds of the cases when compared to the level of care the child actually received during their emergency visit, according to a new study published in JAMA Network Open. Under-triage, or assignment of a lower severity score than the level of care that was needed, was more likely for children who were Black, Hispanic, and those who preferred Spanish compared to English.
“Our study was the first to examine rates of mis-triage in pediatric emergency departments when children present for mental or behavioral health concerns,” said lead author Jennifer Hoffmann, MD, MS, 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. “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, and as we continue to see more and more children with these issues in the emergency department, 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.”
Dr. Hoffmann and colleagues analyzed 74,564 visits for mental or behavioral health complaints among children 5-17 years of age presenting to one of 15 U.S. emergency departments participating in the Pediatric Emergency Care Applied Research Network (PECARN) Registry. The study focused on the Emergency Severity Index (ESI), the triage system used in over 90% of U.S. emergency departments.
The most frequently presenting primary mental health diagnosis groups were depressive disorders (25% of visits) and suicide or self-injury (23% of visits). Aggressive behavior occurred in 24% of the visits.
Over-triage, which involves assigning a higher severity triage score than the level of care the child received throughout their emergency visit, was found in more than half (57%) of visits, while under-triage occurred in approximately 1 in 12 visits (8%). Over-triage was more likely during visits by younger patients and Black patients compared to White patients. Under-triage was more likely among visits by Black and Hispanic patients compared to White patients, as well as in visits with a language preference of Spanish relative to English.
“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,” Dr. Hoffmann advised.
“Underlying drivers for inequities in triage may include implicit bias, which refers to unconscious stereotypes or attitudes,” said Dr. Hoffmann. “Clinicians need education on recognizing their own biases, in order to avoid undue influence on the care they provide. Using automated tools or artificial intelligence (AI) to augment the nurse’s assignment of triage scores might help achieve a more objective assessment, although these strategies require further testing. We also need to make interpretation services in the emergency department more readily accessible to families who prefer a language other than English. Ultimately, accurate and equitable triage systems are needed to match children with the right care at the right time, particularly during times of resource strain.”
In addition to Dr. Hoffmann, authors from Lurie Children’s include Christina R. Rojas, MD, Aron C. Janssen, MD, and Elizabeth R. Alpern, MD, MSCE.
Ann & Robert H. Lurie Children’s Hospital of Chicago is a nonprofit organization committed to providing access to exceptional care for every child. It is the only independent, research-driven children’s hospital in Illinois and one of less than 35 nationally. This is where the top doctors go to train, practice pediatric medicine, teach, advocate, research and stay up to date on the latest treatments. Exclusively focused on children, all Lurie Children’s resources are devoted to serving their needs. Research at Lurie Children’s is conducted through Stanley Manne Children’s Research Institute, which is focused on improving child health, transforming pediatric medicine and ensuring healthier futures through the relentless pursuit of knowledge. Lurie Children’s is the pediatric training ground for Northwestern University Feinberg School of Medicine. It is ranked as one of the nation’s top children’s hospitals by U.S. News & World Report. Emergency medicine-focused research at Lurie Children’s is conducted through the Grainger Research Program in Pediatric Emergency Medicine.
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“Our study was the first to examine rates of mis-triage in pediatric emergency departments when children present for mental or behavioral health concerns,” said lead author Jennifer Hoffmann, MD, MS, 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. “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, and as we continue to see more and more children with these issues in the emergency department, 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.”
Dr. Hoffmann and colleagues analyzed 74,564 visits for mental or behavioral health complaints among children 5-17 years of age presenting to one of 15 U.S. emergency departments participating in the Pediatric Emergency Care Applied Research Network (PECARN) Registry. The study focused on the Emergency Severity Index (ESI), the triage system used in over 90% of U.S. emergency departments.
The most frequently presenting primary mental health diagnosis groups were depressive disorders (25% of visits) and suicide or self-injury (23% of visits). Aggressive behavior occurred in 24% of the visits.
Over-triage, which involves assigning a higher severity triage score than the level of care the child received throughout their emergency visit, was found in more than half (57%) of visits, while under-triage occurred in approximately 1 in 12 visits (8%). Over-triage was more likely during visits by younger patients and Black patients compared to White patients. Under-triage was more likely among visits by Black and Hispanic patients compared to White patients, as well as in visits with a language preference of Spanish relative to English.
“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,” Dr. Hoffmann advised.
“Underlying drivers for inequities in triage may include implicit bias, which refers to unconscious stereotypes or attitudes,” said Dr. Hoffmann. “Clinicians need education on recognizing their own biases, in order to avoid undue influence on the care they provide. Using automated tools or artificial intelligence (AI) to augment the nurse’s assignment of triage scores might help achieve a more objective assessment, although these strategies require further testing. We also need to make interpretation services in the emergency department more readily accessible to families who prefer a language other than English. Ultimately, accurate and equitable triage systems are needed to match children with the right care at the right time, particularly during times of resource strain.”
In addition to Dr. Hoffmann, authors from Lurie Children’s include Christina R. Rojas, MD, Aron C. Janssen, MD, and Elizabeth R. Alpern, MD, MSCE.
Ann & Robert H. Lurie Children’s Hospital of Chicago is a nonprofit organization committed to providing access to exceptional care for every child. It is the only independent, research-driven children’s hospital in Illinois and one of less than 35 nationally. This is where the top doctors go to train, practice pediatric medicine, teach, advocate, research and stay up to date on the latest treatments. Exclusively focused on children, all Lurie Children’s resources are devoted to serving their needs. Research at Lurie Children’s is conducted through Stanley Manne Children’s Research Institute, which is focused on improving child health, transforming pediatric medicine and ensuring healthier futures through the relentless pursuit of knowledge. Lurie Children’s is the pediatric training ground for Northwestern University Feinberg School of Medicine. It is ranked as one of the nation’s top children’s hospitals by U.S. News & World Report. Emergency medicine-focused research at Lurie Children’s is conducted through the Grainger Research Program in Pediatric Emergency Medicine.
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