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Overtriage and Undertriage of Children Presenting to the Emergency Department for Behavioral Health

Jennifer A Hoffmann1, Ashley A Foster2, Christina R Rojas1

  • 1Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.

JAMA Network Open
|March 24, 2026
PubMed

Insights

Overtriage was common in pediatric behavioral health emergency department visits, with higher rates in younger children and minority groups. Undertriage also varied by demographics, highlighting disparities in care.

Area of Science:

  • Pediatric Emergency Medicine
  • Behavioral Health Triage
  • Healthcare Disparities

Background:

  • The Emergency Severity Index (ESI) is standard for US emergency department (ED) triage.
  • ESI's effectiveness in pediatric behavioral health cases is understudied.
  • Accurate triage is crucial for appropriate resource allocation and patient outcomes.

Purpose of the Study:

  • To determine the frequency of overtriage and undertriage in children with behavioral health concerns.
  • To identify demographic and clinical factors associated with triage accuracy.
  • To evaluate the performance of the ESI in this specific pediatric population.

Main Methods:

  • Retrospective cross-sectional study of 78,411 ED visits by children (5-17 years) with behavioral health chief concerns.
  • Data collected from 15 US EDs within the Pediatric Emergency Care Applied Research Network (PECARN) Registry (2021-2023).
  • Triage accuracy (over, under, appropriate) defined by vital signs, GCS, pain, medications, resource use, and disposition; multivariable logistic regression used.

Main Results:

  • Over half (57.1%) of visits were overtriaged, while 8.5% were undertriaged; 34.4% were appropriately triaged.
  • Higher odds of overtriage observed in younger children (5-9 years) and non-Hispanic Black patients compared to White patients.
  • Increased odds of undertriage noted for Hispanic and non-Hispanic Black patients, and those with Spanish language preference.

Conclusions:

  • Overtriage is prevalent in pediatric behavioral health ED visits, with significant variations based on age and race/ethnicity.
  • Undertriage also shows demographic disparities, indicating potential inequities in emergency care access and resource allocation.
  • Further research and refined triage systems are needed for accurate and equitable care of children with behavioral health needs.
Abstract

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