In emergency medicine, triage separates patients who require immediate attention from those who can safely wait for care. However, when it comes to children’s mental or behavioral health, triage scores were found to be incorrect in two-thirds of 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-testing, or assignment of a severity score lower than the level of care required, was more likely for children who were black, Hispanic, and who preferred Spanish over English.
“Our study was the first to examine misdiagnosis rates in pediatric emergency departments when children present for mental or behavioral health concerns,” said lead author Jennifer Hoffman, 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 determinations are incorrect, patient and staff safety can be jeopardized, or resources may be diverted away from children with 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 differentiate levels of urgency upon arrival becomes even more important. We need to make triage tools more accurate and equitable so they are appropriate for all children. Work with those who come to our door looking for care.”
Dr. Hoffman and colleagues analyzed 74,564 visits for mental or behavioral health complaints among children aged 5–17 years at one of 15 U.S. emergency departments participating in the Pediatric Emergency Care Applied Research Network (PECARN) registry. This study focused on the Emergency Severity Index (ESI), a triage system used in more than 90% of US emergency departments.
The most frequently presenting primary mental health diagnostic 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 triage score that is higher than the level of care the child received during their emergency visit, was found in more than half (57%) of the visits, while under-triage occurred in about 1 in 12 visits (8%). Younger patients and black patients were more likely to be over-tested during visits than white patients. Black and Hispanic patients were more likely to be under-triaged compared to white patients, as were visits with a language preference of Spanish relative to English.
Dr. Hoffman advised, “The main message for parents is to advocate for your baby. If you are concerned that your baby is at risk of harming themselves or others while you wait, tell the nurse right away.”
“Underlying drivers of disparities in triage may include implicit bias, which refers to unconscious stereotypes or attitudes,” Dr. Hoffman said. “Physicians need education to recognize their own biases, to avoid undue influence on the care they provide. Using automated tools or artificial intelligence (AI) to enhance nurses’ assignment of triage scores may help achieve more objective assessments, although these strategies require further testing. We need to make interpretation services in the emergency department more easily accessible to families who prefer a language other than English. Finally, Accurate and equitable triage systems are needed to match children to the right care in a timely manner, especially in times of resource strain.”
In addition to Dr. Hoffman, Lurie Children’s authors include Christina R. Rojas, MD, Aaron C. Janssen, MD, and Elizabeth R. Alpern, MD, MSCE.
