Related Experiment Video
Updated: Aug 6, 2026
Hemodynamic Precision in the Neonatal Intensive Care Unit using Targeted Neonatal Echocardiography
Published on: January 27, 2023
Association Between Pediatric ED Triage Accuracy and Timeliness of Care and Patient Outcomes
Daniel D DiLena1, Dana R Sax1,2, Adina S Rauchwerger1
1Kaiser Permanente Division of Research, Pleasanton, California.
Insights
Pediatric emergency department (ED) mistriage is common, leading to care delays. Improving the accuracy of the Emergency Severity Index (ESI) triage system can enhance timely care for all children.
Area of Science:
- Emergency Medicine
- Pediatric Care
- Healthcare Systems Analysis
Background:
- The Emergency Severity Index (ESI) is widely used for ED triage to prioritize critically ill patients.
- Research indicates high rates of triage inaccuracy, particularly in pediatric populations.
- Pediatric mistriage may impact the timeliness and quality of care received.
Purpose of the Study:
- To evaluate the association between pediatric mistriage and the timeliness of care.
- To assess the relationship between pediatric mistriage and patient outcomes, including ED length of stay (LOS).
- To analyze the impact of over- and undertriage on pediatric patient care pathways.
Main Methods:
- Retrospective cohort study of over 1 million pediatric ED encounters (2016-2020) across 21 EDs.
- Utilized validated measures to classify triage accuracy as over-, under-, or accurately triaged.
- Primary outcome: time to initial provider orders; Secondary outcome: ED length of stay (LOS).
Main Results:
- Mistriage occurred in 65.8% of pediatric encounters, with overtriaging being most common (58.5%).
- Under-triaged high-acuity patients experienced longer times to orders (23 min) compared to accurately triaged patients (14 min).
- Over-triaged low-acuity patients faced delays in care (25.3 min vs 21.8 min) and longer ED LOS (118.4 min vs 82.1 min).
Conclusions:
- Pediatric ED mistriage is prevalent and significantly associated with delays in care initiation.
- Enhancing triage accuracy for pediatric patients is crucial for optimizing timely care delivery.
- More accurate triage systems can improve overall patient flow and prioritize the sickest children effectively.
Background And Objectives:
Emergency department (ED) triage promotes timely care for the patients who are sickest. The Emergency Severity Index (ESI) is the most used triage system, although research suggests high rates of mistriage, especially among pediatric patients. We assessed how pediatric mistriage is associated with timeliness of care and patient outcomes.
Methods:
We conducted a retrospective cohort study of patients aged less than 18 years with an ED encounter across 21 EDs from 2016 to 2020. Using validated measures of triage accuracy, we assessed how assigned ESI level aligned with downstream care and resource use, classifying encounters as over-, under- or accurately triaged. The primary outcome was timeliness of care, defined by time to initial provider orders, and the secondary outcome was ED length of stay (LOS).
Results:
Among 1 015 866 encounters (median aged 6 [IQR, 2-12] years; 47.2% girls), mistriage occurred in 65.8% of encounters, the majority being overtriaged (58.5%). Patients of high acuity had longer time to orders if undertriaged (23 minutes) vs accurately triaged (14 minutes). Patients of low acuity that were overtriaged had delays in care (time to orders 25.3 vs 21.8 minutes) and greater ED LOS (118.4 vs 82.1 minutes) compared with patients of low acuity that were accurately triaged. All time differences were statistically significant.
Conclusions:
Mistriage is common in pediatric ED care and is associated with delays in initiating care. Improving accurate triage for pediatric patients may allow for more timely care overall while still prioritizing treatment of the patients that are sickest.
