When children arrive at the emergency department (ED) with behavioral health symptoms like suicidal thoughts, anxiety, or behavioral crises, a triage nurse quickly decides how urgently they need care. But does this process work equally well for all children?
A new PECARN study “Overtriage and Undertriage of Children Presenting to the Emergency Department for Behavioral Health” [DOI] published in JAMA Network Open found that triage errors are common and that some groups of children are affected more than others [1].
Study Design
Hoffmann et al. analyzed 78,411 ED visits by children aged 5 to 17 with behavioral health concerns across 15 PECARN sites from 2021 to 2023. They compared each child’s triage score against what actually happened during their visit to determine whether the child was appropriately triaged, overtriaged (assigned a higher urgency than needed), or undertriaged (assigned a lower urgency than needed).
Results
Of the 74,564 visits with complete data, 57% were overtriaged, 34% were appropriately triaged, and 8.5% were undertriaged. Only about one in three children was triaged accurately.
While 8.5% may sound small, that translates to over 6,300 children across just 15 EDs over 3 years whose level of need was underestimated. And those errors were not distributed equally.
Undertriage was not equal across groups. After accounting for clinical and visit characteristics, undertriage was significantly more likely for Hispanic children, non-Hispanic Black children, and children from Spanish-speaking families, all compared to non-Hispanic White and English-speaking patients [1]. The authors point to unconscious clinician bias, systemic racism, and underuse of professional interpreters as likely contributors.
Overtriage was also unequal. The strongest predictor was age: children aged 5 to 9 were over 4 times more likely to be overtriaged than those aged 10 to 14, possibly because younger children have difficulty expressing their symptoms. Non-Hispanic Black children were also more likely to be overtriaged, to a lesser degree. This means Black children were more likely to experience both types of triage error compared to White children, suggesting different biases at different points in care.
Why This Matters
Undertriage can have real consequences. Children whose urgency is underestimated may wait longer, miss critical interventions, or leave the ED without being seen. The fact that these errors fell more heavily on Hispanic, Black, and Spanish-speaking children points to a systemic problem that needs to be addressed. The authors call for prospective studies to design triage approaches that are both accurate and fair for all children.
Take Home Message
Triage errors are common among children presenting to the ED with behavioral health concerns. More importantly, undertriage disproportionately affects Hispanic, Black, and Spanish-speaking children. Better triage practices and tools are needed to ensure all children receive equitable care.
Why is this important for patients and caregivers
- When your child visits the ED for a behavioral health concern, a triage nurse decides how quickly they need to be seen. This study found that children from Hispanic, Black, and Spanish-speaking families were more likely to have their level of need underestimated.
- Undertriage can mean longer waits or missed care at a time when your child is in crisis.
- If you feel your child’s needs are not being addressed promptly, you can ask for reassessment or to speak with a charge nurse or patient advocate.
References
- Hoffmann JA, Foster AA, Rojas CR, et al. Overtriage and undertriage of children presenting to the emergency department for behavioral health. JAMA Netw Open. 2026;9(3):e263042. doi:10.1001/jamanetworkopen.2026.3042
