Emergency Triage Inaccurate for Children’s Mental Health – Racial Disparities Found
Accurate assessment of a child’s mental health needs in the emergency department can be surprisingly difficult, and new research suggests that current triage systems frequently misjudge the severity of a child’s condition. A study published in JAMA Network Open reveals that triage scoring—the process of quickly evaluating patients to determine the urgency of their care—is inaccurate in approximately two-thirds of cases involving children presenting with mental or behavioral health concerns. This means children may either receive care too slowly (under-triage) or be unnecessarily escalated to a higher level of care (over-triage).
The study, led by Jennifer Hoffmann, MD, MS, an emergency physician and researcher at Ann &. Robert H. Lurie Children’s Hospital of Chicago, analyzed data from over 74,000 emergency department visits across 15 hospitals in the United States. Researchers focused on visits by children aged 5 to 17 who were experiencing mental or behavioral health issues. The findings highlight significant disparities in triage accuracy based on race and language preference, raising concerns about potential biases in the system. You can identify more details about the Pediatric Emergency Care Applied Research Network (PECARN) here.
Disparities in Triage Accuracy
The Emergency Severity Index (ESI), a widely used triage system in over 90% of US emergency departments, aims to quickly categorize patients based on the urgency of their needs. However, the study found that the ESI frequently misclassified the severity of mental health crises in children. Over-triage – assigning a higher urgency level than ultimately needed – occurred in more than half (57%) of the visits. Under-triage, where a child’s needs were underestimated, occurred in about 8% of visits.
Importantly, the research revealed that these errors weren’t evenly distributed. Younger children and Black patients were more likely to be over-triaged, while Black and Hispanic children, as well as those who preferred to communicate in Spanish, were more likely to be under-triaged. This suggests that systemic factors, such as implicit biases or language barriers, may be contributing to these discrepancies. The full study can be found on the JAMA Network Open website.
Common Mental Health Presentations in the ED
The study categorized the primary reasons children visited the emergency department for mental health support. Depressive disorders accounted for 25% of visits, while suicidal thoughts or self-harm attempts comprised 23%. Aggressive behavior was observed in 24% of cases. These findings underscore the diverse range of mental health challenges that bring children to emergency settings, and the complexity of accurately assessing their needs.
What Does This Mean for Families?
For parents and caregivers, these findings emphasize the importance of advocating for their child’s needs in the emergency department. “If you are concerned that your child is at risk of harming themselves or others while waiting for care, immediately inform the triage nurse,” advises Dr. Hoffmann. Trust your instincts and don’t hesitate to voice your concerns if you perceive your child’s situation isn’t being adequately assessed.
The Role of Implicit Bias and Language Access
Dr. Hoffmann and her colleagues suggest that implicit biases – unconscious stereotypes or attitudes – may play a role in the observed triage disparities. These biases can influence how healthcare professionals perceive and evaluate patients, potentially leading to inaccurate assessments. Addressing these biases requires ongoing education and training for emergency department staff.
the study highlights the critical need for improved language access services in emergency departments. Children and families who prefer languages other than English may face communication barriers that hinder accurate triage. Ensuring readily available and qualified interpreters is essential for equitable care. The Société française de médecine d’urgence (SFMU) publishes research on emergency medicine, including triage, and can be found here (site is in French).
Beyond Triage: Improving Pediatric Mental Health Care
While improving triage accuracy is crucial, it’s only one piece of the puzzle. The current crisis in youth mental health demands a comprehensive approach that includes increased access to mental health services, early intervention programs, and improved support for families. The increasing number of children presenting with mental health concerns in emergency departments underscores the urgent need for systemic change.
Researchers are exploring the potential of automated tools and artificial intelligence (AI) to assist with triage scoring, aiming for a more objective evaluation process. However, Dr. Hoffmann cautions that these technologies require rigorous testing and validation before widespread implementation.
What’s Next for Pediatric Emergency Mental Health?
The findings from this study are prompting further investigation into the factors contributing to triage inaccuracies and disparities. Future research will focus on developing and evaluating interventions to mitigate bias, improve language access, and enhance the overall quality of mental health care for children in emergency settings. Continued monitoring of triage performance and ongoing education for emergency department staff are as well essential steps. For more information on child and adolescent health, including mental health resources, visit JAMA Pediatrics.