Accuracy and Disparities in Pediatric Emergency Triage: A Multicenter Retrospective Cohort Study

OBJECTIVES To assess the accuracy of the Emergency Severity Index (ESI) in correctly stratifying high-risk pediatric patients and predicting resource use across multiple pediatric emergency departments (EDs), and to identify patient and environmental factors associated with triage accuracy. BACKGROUND The ESI is widely used for ED triage in the United States, yet its performance in pediatric populations remains suboptimal. Limited multicenter data exist on factors contributing to inaccurate triage in children’s hospitals. METHODS We performed a cross-sectional cohort study using the Pediatric Emergency Care Applied Research Network (PECARN) Registry database from 2012 to 2023. The database includes 17 pediatric EDs across the United States. Undertriage was defined as greater than expected resource usage or acuity compared to the ESI level assigned at triage, and overtriage as being assigned an ESI level exceeding actual care provided. We used multivariable analysis to assess associations between triage accuracy and patient demographics and ED visit characteristics. RESULTS We evaluated 7.3 million visits. Accuracy was 33% overall, with 35% overtriaged and 32% undertriaged. Undertriage was more common among adolescents, non-English speakers, and minoritized populations. Overtriage was associated with newborn age and ED crowding. Patients who presented for complaints associated with standardized treatment protocols had higher accuracy rates. CONCLUSIONS ESI performance in PECARN Registry pediatric EDs was low, with accuracy varying by age, language, race, and ethnicity. Evidence-based guidelines and decision support tools may improve triage accuracy and reduce inequities.