Undertriage and Delayed Asthma Treatment in Pediatric Emergency Medicine Patients

Asthma is the most common chronic disease of childhood, accounting for more than 1 million annual emergency department (ED) and urgent care visits and more than 27,000 hospitalizations each year [1]. Timely management is important; high-quality asthma care is defined as providing standard therapies within sixty minutes of arrival at the ED [2]. When triage underestimates illness severity, a phenomenon known as undertriage, patients may not receive timely interventions such as nebulization therapy, oxygen, intravenous medications, or admission decisions [3, 4]. This is particularly concerning in asthma management, where early escalation is often essential [5]. Despite its clinical relevance, the impact of undertriage in pediatric asthma has not been well studied. We conducted a retrospective case–control study to evaluate the association between clinically important undertriage and delays in ordering treatment and disposition, as well as subsequent risks of hospital admission and return visits. The Emergency Severity Index (ESI), a five-level triage tool, is widely used across U.S. EDs to stratify patients based on acuity and anticipated resource needs [6]. Triage level is determined on arrival by a dedicated triage nurse using ESI guidelines. At our urban, academic, tertiary-care pediatric ED, which sees approximately 90,000 visits annually, more than half of patients are triaged as low-acuity, ESI 4 or 5, a trend seen in similar institutions [7]. Using the pediatric asthma score, a point-based tool that correlates vitals and exam findings with illness severity, nurses can initiate an asthma pathway. For asthma scores ≥ 4, typically corresponding to ESI 3 or higher, the asthma pathway includes nebulized albuterol and dexamethasone. For scores ≤ 3, typically ESI 4 or 5, the pathway includes nebulized albuterol alone. Patients triaged as low acuity are placed in an ED area designated for minor concerns. This area has fewer resources, including no wall-mounted medical gases, and reduced staffing, although continuously staffed by physicians, advanced practice providers, and nurses. We defined clinically important undertriage as cases in which patients were triaged as ESI 4 or 5 but subsequently required emergency interventions typically associated with higher acuity levels. We identified patients aged 2 to 21 years who presented to the ED between July 1, 2021 and June 30, 2024 with a primary asthma diagnosis (ICD-10 J45. X or J46. X), an ESI score of 4 or 5, and received at least one of the following: high-dose nebulized medication, supplemental oxygen beyond what is used for nebulized medication delivery, intravenous (IV) medications, bi-level positive airway pressure (BIPAP), or hospital admission. Controls were selected from patients triaged as ESI 3 who were treated for asthma and matched to cases based on the same intervention received. To account for operational delays in care such as variations in staffing, throughput, and patient volumes, controls were further matched by date and time of arrival (±2 h). The institutional review board approved this study. We extracted demographic and visit-level data from the electronic health record, including reason for visit, time to provider evaluation, time to ordering of emergency treatments, and time to ED disposition. Disposition was defined as admission to the general floor, admission to the intensive care unit (ICU), or discharge. Primary outcome measures included time to provider, time to order of emergency treatments (oxygen, nebulized medications, IV medications, intramuscular (IM) epinephrine), and time to disposition order as a marker of ED length of stay. Secondary outcome measures included likelihood of ICU or floor admission and return visits within two weeks. Nebulized medication was defined as the administration of more than 5 mg of albuterol, which exceeds two standard single doses for younger children or one standard dose for older children. IV medications included fluids, IM epinephrine, methylprednisolone, and magnesium sulfate. Although patients triaged as ESI 4 are expected to require minimal resources, the need for high-dose nebulized treatments, supplemental oxygen, or IV access suggests respiratory or circulatory instability and may warrant a higher ESI classification. Continuous variables (e.g., time to orders) were analyzed using Wilcoxon rank sum tests and reported with interquartile ranges. Categorical outcomes, including likelihood of admission and return visits, were analyzed using odds ratios with 95% confidence intervals. A p < 0.05 was considered statistically significant. Statistical analyses were performed using Python v3.10 (Python Software Foundation, https://www.python.org) and the scipy module. A p < 0.05 was considered statistically significant. During the study period, 7525 patients presented to the ED with asthma exacerbations. Of these, 1413 (18.8%) were triaged ESI 4 or 5, and 2908 (38.6%) were triaged ESI 3. Among asthma patients triaged as ESI 4/5, 304 (21.5%) met criteria for clinically important undertriage. Among those triaged as ESI 3, there were 2132 (73.3%) who met criteria for the control pool, and 94 were successfully matched to undertriaged cases. Among the 94 matched undertriaged cases, 13 (13.8%) were admitted, 3 (3.2%) required supplemental oxygen, 91 (96.8%) received nebulized medications, 81 (86.2%) received dexamethasone, 1 (1.1%) required IM epinephrine, and 16 (17.0%) required IV access. Most cases and controls were school-aged with mean ages of 7.9 +/− 5.1 years and 8.1 +/− 5.0 years, respectively. A majority were male (59.6% of cases and 51.1% of controls). More than half identified as non-Hispanic Black (59.6% of cases and 69.1% of controls), and approximately one-quarter identified as Hispanic (27.7% and 23.4%, respectively) consistent with our overall ED population. Compared to controls, undertriaged patients experienced significant delays in care. Time to order of nebulized medications was 3.5 h (IQR 2–4.8) versus 0.9 h (IQR 0.5–2.7) for controls (p < 0.001). Time to dexamethasone was similarly delayed: 3.5 h (IQR 2.1–4.8) versus 0.9 h (IQR 0.5–2.7) (p < 0.001). Median time to provider was also prolonged among undertriaged patients, at 2.5 h (IQR 1.2–4.0) compared to 0.8 h (IQR 0.3–2.2) for controls (p < 0.0001) (Figure 1). There was not a significant difference in median time to disposition: 7.9 h (IQR 5,11.9) undertriaged patients versus. 7.2 (IQR 5.2, 10.9) for controls (p = 0.8). Time to IV fluid orders did not differ significantly (6.5 h (IQR 2.1, 8.5) vs. 3.3 (IQR 1.1, 5.6), p = 0.25). The number of patients requiring supplemental oxygen or IM epinephrine was too small to determine statistical significance. There were no significant differences in the likelihood of ICU admission (OR 1.0; 95% CI, 0.14–7.25), general admission (OR 0.73; 95% CI, 0.33–1.60), or return visits within 2 weeks (OR 0.49; 95% CI 0.04–5.55). To the best of our knowledge, this is the first study to identify the impacts of clinically important undertriage on ED patients presenting with asthma. Notably, we found that 21.5% of ESI 4 or 5 patients presenting to the pediatric ED for asthma met criteria for clinically important undertriage. While not all asthma patients triaged as ESI 4 or 5 require corticosteroids, we found that both albuterol and dexamethasone were administered significantly later to undertriaged patients, with delays exceeding 90 min. Timely treatment is essential in the management of asthma exacerbations, as even small delays in care can lead to worsening respiratory distress and prolonged ED stays [5]. Undertriaged asthma patients also experienced longer wait times from triage to provider. We selected time to order of interventions as the primary metric as it better reflects delays in clinical recognition, is measurable, and more accurately reflects the effect of undertriage on recognizing the need for escalated care. Undertriage also increases the risk of designating patients for low-acuity pods, where limited monitoring, and fewer available resources and staff may delay escalation. These pods are designed for efficiency, but initial triage assessment impacts the timeliness of care. Our findings align with prior research in adult populations, which show that undertriage contributes to delays in time-sensitive interventions and increases the risk of clinical deterioration [8, 9]. Our study adds to the limited data in the pediatric ED population. Prior work by Berkowitz et al. found that undertriaged pediatric patients experienced care delays and were more likely to return or require emergency intervention [3]. In our asthma-specific cohort, we similarly observed delays in care. However, we did not find increased rates of admission, return visits, or delayed disposition. We suspect our sample size was too small to detect a difference. Another possibility is that dexamethasone correlates with decreased lengths of active treatment [5]. This study has limitations. It was conducted at a single site with a dedicated low-acuity area, which may not reflect other ED environments. While we matched cases by time of arrival, unmeasured operational factors could have influenced delays. Our findings contribute to the limited but growing body of research on pediatric undertriage, highlighting its complexity and the need for more focused studies across a range of conditions. Undertriage remains underexplored in clinical ED practice, despite clear implications for patient safety and throughput. Given the high prevalence of pediatric asthma and the time-sensitive nature of its treatment, delays related to undertriage should be viewed as a priority for safety and quality improvement efforts. Undertriage also warrants attention as a meaningful quality metric, as it directly affects timeliness and efficiency, two core components of healthcare quality. Drs. Berkowitz, Chamberlain, and McCollum conceptualized and designed the study, collected and analyzed data, and contributed to drafting the initial manuscript and critically reviewed the work. Dr. Maya McKeown analyzed data and contributed to drafting the initial manuscript and critically reviewed the work. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. The data that support the findings of this study are available from the corresponding author upon reasonable request.