Why Over- and Undertriage Disproportionately Affects Black and Hispanic Children in the Emergency Department

Emergency departments (EDs) are often the first and sometimes only place children receive care during a behavioral health crisis. However, new research suggests that the way children are triaged in such high-pressure environments is not always consistent, with both overtriage and undertriage occurring more frequently than expected.

Triage accuracy is critical in emergency departments, and inaccuracies can have serious consequences for children’s safety, treatment timelines, and long-term mental health outcomes.

What the Study Found

Overtriage is common among children presenting to the emergency department (ED) with behavioral health symptoms, according to a study published online March 24 in JAMA Network Open. 

Jennifer A. Hoffmann, M.D., from the Ann & Robert H. Lurie Children’s Hospital of Chicago, and colleagues examined the frequency of overtriage and undertriage among children presenting to the ED with behavioral health symptoms in a retrospective cross-sectional study performed in 15 U.S. EDs.

The analysis included 78,411 ED visits by children and adolescents with a behavioral health chief concern. The researchers found that of the 74,564 visits with nonmissing data, 34.4, 57.1, and 8.5 percent were appropriately triaged, overtriaged, and undertriaged, respectively. The adjusted odds of overtriage were higher for visits by children aged 5 to 9 years versus those aged 10 to 14 years and for visits by non-Hispanic Black versus non-Hispanic White patients (adjusted odds ratios, 4.43 and 1.17, respectively). The adjusted odds of undertriage were higher for visits by Hispanic and non-Hispanic Black versus non-Hispanic White patients (adjusted odds ratios, 1.46 and 1.28, respectively) and for those with a Spanish versus English language preference (adjusted odds ratio, 1.31).

“Underlying drivers for inequities in triage may include implicit bias, which refers to unconscious stereotypes or attitudes,” Hoffman said in a statement. “Clinicians need education on recognizing their own biases in order to avoid undue influence on the care they provide. Using automated tools or artificial intelligence to augment the nurse’s assignment of triage scores might help achieve a more objective assessment, although these strategies require further testing.”

One author disclosed ties to Abbott Laboratories.

Triage Challenges in Pediatric Behavioral Health

ED visits for behavioral health concerns can often be some of the most complex cases for healthcare professionals. Unlike more clear-cut situations, such as physical injuries or acute medical emergencies, symptoms like aggression, anxiety, emotional dysregulation, or suicidal ideation may fluctuate rapidly — or present differently depending on the child’s age, environment, or communication ability.

In the emergency department, providers are often forced to make quick decisions with limited context, which can lead to two types of errors: undertriage (the child’s condition is not recognized as urgent enough) and overtriage (the child is classified as more acute than necessary).

Both situations can disrupt care, with undertriage delaying critical mental health intervention, while overtriage can strain the often-limited psychiatric services offered in EDs and lead to unnecessary hospitalization.

Where Disparities Begin to Emerge

While triage inconsistencies affect all pediatric patients, research consistently shows that Black and Hispanic children often experience different patterns of emergency care compared to their white counterparts.

In mental health presentations, particularly, disparities may show up in many ways:

• Biases in how symptom severity is perceived or documented.
• Differences in admission rates or use of restraint or sedation. 
• Variability in the likelihood of receiving urgent psychiatric evaluations.
• Inequities in access to follow-up psychiatric care after discharge.

These disparities can often persist even when the clinical presentation is controlled, suggesting that non-medical factors (e.g., the social determinants of health) may influence decision-making in high-stakes environments.

Why These Gaps May Be Happening

Several overlapping factors may be contributing to inequities in pediatric behavioral health triage, including:

• Implicit bias in high-stress environments: ED providers are making quick decisions under significant pressure. In these situations, unconscious biases can trickle in, influencing how patients’ symptoms are interpreted.
• Communication barriers: Differences in language, cultural expression, or health literacy can affect how providers interpret symptoms of distress. 
• Structural inequities in care access: Black and Hispanic children are more likely to rely on emergency departments for mental healthcare due to limited access to outpatient services. This barrier often means they come in during crises with more complex needs.
• Resource limitations in ED settings: Unfortunately, many EDs lack sufficient resources for pediatric behavioral health, often leading to inconsistent assessments and reliance on general triage protocols that don’t capture the patient’s complete psychiatric profile. 

What Providers Can Do to Improve Equity in Triage

Addressing the inequities in pediatric behavioral health in emergency departments will require both a system-level change and individual clinical awareness.

Some strategies that may help include:

• Standardizing pediatric behavioral health screenings.
• Strengthening linguistic and cultural competency.
• Implementing trauma-informed care principles.
• Investing in education focused on bias awareness.
• Expanding access to pediatric mental health support.
• Tracking and reviewing equity data to identify patterns of disparity.

The Takeaway

Pediatric behavioral health visits in the emergency department continue to rise across the country, and triage systems are being asked to handle increasingly complex cases under high pressure.

However, the latest research underscores a critical truth: how we access urgency is just as important as how we treat it.

For Black and Hispanic children, in particular, improving triage accuracy is a crucial step towards reducing the long-standing inequities these communities face in accessing pediatric mental healthcare.

As ED providers continue to be the first-line mental health providers for many individuals and families, ensuring fairness, consistency, and cultural competency in triage can be one of the most important interventions.

Are you a healthcare professional? Register with us today!