Over-Triage and Under-Triage Common in Pediatric Emergency Department Behavioral Health Cases
Chicago, IL – A significant proportion of children presenting to emergency departments (EDs) with behavioral health concerns are subjected to over-triage, meaning they receive a higher level of care than necessary. Conversely, a notable percentage are also under-triaged, indicating they do not receive the appropriate level of care. These findings, stemming from a comprehensive study published online on March 24, 2026, in JAMA Network Open, highlight potential systemic issues in how pediatric behavioral health emergencies are managed within the U.S. healthcare system.
The research, spearheaded by Dr. Jennifer A. Hoffmann and her team at Ann & Robert H. Lurie Children’s Hospital of Chicago, delved into the frequency of both overtriage and undertriage among young patients seeking emergency care for behavioral health symptoms. Utilizing a retrospective cross-sectional study design, the analysis encompassed data from 15 emergency departments across the United States.
Key Findings from the Study:
- Extensive Data Analysis: The study examined a substantial cohort of 78,411 emergency department visits made by children and adolescents who presented with a chief concern related to behavioral health.
- Prevalence of Triage Discrepancies: After excluding visits with missing data, a total of 74,564 visits were analyzed. The results revealed that:
- 34.4 percent of these visits were appropriately triaged.
- A significant 57.1 percent were over-triaged.
- 8.5 percent were undertriaged.
- Demographic Factors Influencing Triage: The study identified specific demographic groups at higher risk for disparate triage outcomes.
- Increased Odds of Overtriage:
- Children aged 5 to 9 years were found to have higher adjusted odds of being over-triaged compared to those aged 10 to 14 years (adjusted odds ratio, 4.43).
- Non-Hispanic Black patients experienced higher adjusted odds of overtriage when compared to non-Hispanic White patients (adjusted odds ratio, 1.17).
- Increased Odds of Undertriage:
- Hispanic and non-Hispanic Black patients showed higher adjusted odds of undertriage compared to non-Hispanic White patients (adjusted odds ratios of 1.46 and 1.28, respectively).
- Patients with a Spanish language preference had higher adjusted odds of undertriage compared to those with an English language preference (adjusted odds ratio, 1.31).
- Increased Odds of Overtriage:
Addressing the Root Causes and Potential Solutions
Dr. Hoffmann pointed to implicit bias as a potential underlying driver for these observed inequities in triage. Implicit bias refers to the unconscious stereotypes and attitudes that can inadvertently influence clinical decision-making. “Clinicians need education on recognizing their own biases, in order to avoid undue influence on the care they provide,” she stated. This underscores the critical need for ongoing training and awareness programs for healthcare professionals working in high-pressure environments like emergency departments.
The study also explored potential technological interventions to mitigate these issues. The researchers suggested that the integration of automated tools or artificial intelligence (AI) could serve to augment the nurse’s assignment of triage scores, potentially leading to more objective assessments. However, they emphasized that such strategies require further rigorous testing and validation before widespread implementation. The goal is to leverage technology to support, rather than replace, the clinical judgment of experienced healthcare providers.
The implications of these findings are far-reaching. Over-triage can lead to unnecessary resource utilization, increased costs for both patients and healthcare systems, and potentially expose children to more invasive or prolonged evaluations than necessary. Conversely, under-triage can result in delayed or inadequate care, potentially leading to adverse health outcomes for vulnerable children experiencing behavioral health crises.
Moving forward, healthcare institutions and policymakers will need to consider these findings carefully. Strategies to address implicit bias, enhance cultural competency training, and explore the judicious use of technology are crucial steps in ensuring that all children receive equitable and appropriate care when they present to the emergency department with behavioral health concerns. The study serves as a vital call to action for improving the quality and fairness of care delivery in this critical area of pediatric health.
