When Kids Comes to the ER with Mental Health Needs

When patients come to a crowded emergency department (ED), staff members, usually nurses, need to make quick decisions: Does this person have a serious condition and need prompt attention, or can they wait a little while so the more serious cases can be addressed first? This is the process called triage.

When ED staffers triage children with symptoms of mental health conditions, how good a job do they do? Not very good, according to a recent study in JAMA Pediatrics.  

Only about a third of the cases were triaged appropriately and the majority – about 57% – were “overtriaged,” meaning the condition of a patient was initially judged to be more serious than the treatment they ended up receiving. Just 8% of the entire group was “undertriaged” – meaning their condition was initially judged to be more minor – and that was more likely to happen to Hispanic and Black children than white children.

The study reviewed the cases of more than 74,500 pediatric visits at 15 different emergency departments around the country from 2021 through 2023. It found that younger children were more likely to be overtriaged, said Dr. Jennifer Hoffman, an author of the study.

“There are a lot of pressures in the triage area to do this in a rapid manner,” she told MindSite News. “We know sometimes when nurses are making these subjective judgements it can be prone to implicit bias, which means that there may be unconscious biases that are factoring into some of their decisions and assessments.”

While being overtriaged may not seem like the worst thing to parents or patients, it can create problems for the hospital system, said Hoffman, assistant professor of pediatrics at Northwestern University Feinberg School of Medicine. 

“Over-triaging typically leads to the patient being roomed earlier, when they actually were safe to wait in the waiting room. This can pull resources away from other children who actually need urgent attention,” Hoffman told MindSite News.

Under-triaging can also have harmful effects for patients, she said.

“If a child who is at risk of harming themselves or another person is in the waiting room for a long time, there is a risk of elopement, which means that they might leave before they’re seen and evaluated by a provider. There’s also a risk of the child becoming escalated while they’re in the waiting room, which could potentially be harmful to other patients and families waiting.”

The findings suggest that triaging behavioral health visits in the emergency department changed based on the patient’s race, age and language spoken, highlighting the need  to improve the assessment process.

While the study didn’t explore solutions — only identify the problem — Hoffman pointed to updating the tools nurses are using to assess patients, providing more guidance on how to assign scores for the assessment and improving nurse education on applying criteria or updating the criteria as ways to improve the process.

Another possible option to consider, Hoffman says: Artificial Intelligence.

“If AI tools are thoughtfully designed and implemented, there is potential for some of that data to be used to help make more objective decisions, instead of relying on subjective judgment, which is more prone to bias,” she said.