{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,21]],"date-time":"2026-10-21T01:43:00Z","timestamp":1792546980233,"version":"4.5.0"},"reference-count":53,"publisher":"American Academy of Pediatrics (AAP)","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:sec>\n                    <jats:title>OBJECTIVES<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>BACKGROUND<\/jats:title>\n                    <jats:p>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\u2019s hospitals.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>METHODS<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESULTS<\/jats:title>\n                    <jats:p>We evaluated 7.3\u00a0million 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSIONS<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1542\/hpeds.2026-009554","type":"journal-article","created":{"date-parts":[[2026,9,17]],"date-time":"2026-09-17T00:02:47Z","timestamp":1789603367000},"source":"Crossref","is-referenced-by-count":1,"title":["Accuracy and Disparities in Pediatric Emergency Triage: A Multicenter Retrospective Cohort Study"],"prefix":"10.1542","author":[{"given":"Warren D","family":"Frankenberger","sequence":"first","affiliation":[{"name":"1Children\u2019s Hospital of Philadelphia, Center for Pediatric Nursing Research and Evidence-Based Practice, Philadelphia, Pennsylvania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Camille P.","family":"Carter","sequence":"additional","affiliation":[{"name":"2Utah Data Coordinating Center, University of Utah, Salt Lake City, Utah"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cody S.","family":"Olsen","sequence":"additional","affiliation":[{"name":"2Utah Data Coordinating Center, University of Utah, Salt Lake City, Utah"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Huong D.","family":"Meeks","sequence":"additional","affiliation":[{"name":"2Utah Data Coordinating Center, University of Utah, Salt Lake City, Utah"},{"name":"3Department of Pediatrics, University of Utah, Salt Lake City, Utah"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joseph J.","family":"Zorc","sequence":"additional","affiliation":[{"name":"4Children\u2019s Hospital of Philadelphia, Department of Pediatrics, Division of Emergency Medicine, Philadelphia, Pennsylvania"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"417","published-online":{"date-parts":[[2026,9,17]]},"reference":[{"issue":"1","key":"2026091620024432700_r1","doi-asserted-by":"crossref","first-page":"106","DOI":"10.1111\/j.1553-2712.2011.01240.x","article-title":"More patients are triaged using the Emergency Severity Index than any other triage acuity system in the United States","volume":"19","author":"McHugh","year":"2012","journal-title":"Acad Emerg Med."},{"issue":"6","key":"2026091620024432700_r2","doi-asserted-by":"crossref","first-page":"677","DOI":"10.1016\/j.jen.2019.05.006","article-title":"Are emergency departments in the United States following recommendations by the Emergency Severity Index to promote quality triage and reliability?","volume":"45","author":"Worth","year":"2019","journal-title":"J Emerg Nurs."},{"issue":"1","key":"2026091620024432700_r3","doi-asserted-by":"crossref","first-page":"140","DOI":"10.1016\/j.annemergmed.2018.09.022","article-title":"Triage performance in emergency medicine: a systematic review","volume":"74","author":"Hinson","year":"2019","journal-title":"Ann Emerg Med."},{"issue":"1","key":"2026091620024432700_r4","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1186\/s12245-017-0161-8","article-title":"Accuracy of emergency department triage using the Emergency Severity Index and independent predictors of under-triage and over-triage in Brazil: a retrospective cohort analysis","volume":"11","author":"Hinson","year":"2018","journal-title":"Int J Emerg Med."},{"issue":"1","key":"2026091620024432700_r5","doi-asserted-by":"crossref","first-page":"40","DOI":"10.1016\/j.ienj.2013.01.003","article-title":"The cognitive processes underpinning clinical decision in triage assessment: a theoretical conundrum?","volume":"22","author":"Noon","year":"2014","journal-title":"Int Emerg Nurs."},{"issue":"2","key":"2026091620024432700_r6","doi-asserted-by":"crossref","first-page":"96","DOI":"10.1097\/PEC.0000000000002342","article-title":"Cognitive errors in pediatric emergency medicine","volume":"37","author":"Scarfone","year":"2021","journal-title":"Pediatr Emerg Care."},{"issue":"2","key":"2026091620024432700_r7","doi-asserted-by":"crossref","first-page":"220","DOI":"10.1016\/j.jen.2018.12.016","article-title":"Clinical decision support systems in the emergency department: opportunities to improve triage accuracy","volume":"45","author":"Stone","year":"2019","journal-title":"J Emerg Nurs."},{"issue":"9","key":"2026091620024432700_r8","doi-asserted-by":"crossref","first-page":"843","DOI":"10.1111\/j.1553-2712.2009.00494.x","article-title":"Reliability and validity of the emergency severity index for pediatric triage","volume":"16","author":"Travers","year":"2009","journal-title":"Acad Emerg Med."},{"issue":"10","key":"2026091620024432700_r9","doi-asserted-by":"crossref","first-page":"1027","DOI":"10.1001\/jamapediatrics.2024.2671","article-title":"Emergency Severity Index Version 4 and triage of pediatric emergency department patients","volume":"178","author":"Sax","year":"2024","journal-title":"JAMA Pediatr."},{"issue":"11","key":"2026091620024432700_r10","doi-asserted-by":"crossref","first-page":"751","DOI":"10.1097\/PEC.0b013e3181b0a0c6","article-title":"The Emergency Severity Index version 4: reliability in pediatric patients","volume":"25","author":"Durani","year":"2009","journal-title":"Pediatr Emerg Care."},{"issue":"8","key":"2026091620024432700_r11","doi-asserted-by":"crossref","first-page":"753","DOI":"10.1097\/PEC.0b013e3182621813","article-title":"Emergency Severity Index version 4: a valid and reliable tool in pediatric emergency department triage","volume":"28","author":"Green","year":"2012","journal-title":"Pediatr Emerg Care."},{"key":"2026091620024432700_r12","author":"American College of Physicians"},{"issue":"12","key":"2026091620024432700_r13","doi-asserted-by":"crossref","first-page":"765","DOI":"10.1097\/PEC.0000000000000658","article-title":"Predictors of emergency department utilization among children in vulnerable families","volume":"33","author":"Flood","year":"2017","journal-title":"Pediatr Emerg Care."},{"issue":"2","key":"2026091620024432700_r14","doi-asserted-by":"crossref","first-page":"366","DOI":"10.1055\/s-0038-1651496","article-title":"The Pediatric Emergency Care Applied Research Network registry: a multicenter electronic health record registry of pediatric emergency care","volume":"9","author":"Deakyne Davies","year":"2018","journal-title":"Appl Clin Inform."},{"issue":"4","key":"2026091620024432700_r15","doi-asserted-by":"crossref","first-page":"344","DOI":"10.1016\/j.jclinepi.2007.11.008","article-title":"The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies","volume":"61","author":"von Elm","year":"2008","journal-title":"J Clin Epidemiol."},{"key":"2026091620024432700_r16","doi-asserted-by":"crossref","DOI":"10.1097\/PEC.0000000000002072","article-title":"Racial\/ethnic disparities in triage scores among pediatric emergency department fever patients","author":"Dennis","year":"2021","journal-title":"Pediatr Emerg Care."},{"issue":"2","key":"2026091620024432700_r17","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1016\/j.jen.2023.11.009","article-title":"Triage accuracy in pediatrics using the Emergency Severity Index","volume":"50","author":"Frankenberger","year":"2024","journal-title":"J Emerg Nurs."},{"issue":"10","key":"2026091620024432700_r18","doi-asserted-by":"crossref","first-page":"e2337557","DOI":"10.1001\/jamanetworkopen.2023.37557","article-title":"Race and ethnicity and primary language in emergency department triage","volume":"6","author":"Joseph","year":"2023","journal-title":"JAMA Netw Open."},{"issue":"1","key":"2026091620024432700_r19","doi-asserted-by":"crossref","first-page":"199","DOI":"10.1186\/1471-2431-14-199","article-title":"Pediatric complex chronic conditions classification system version 2: updated for ICD-10 and complex medical technology dependence and transplantation","volume":"14","author":"Feudtner","year":"2014","journal-title":"BMC Pediatr."},{"issue":"7","key":"2026091620024432700_r20","doi-asserted-by":"crossref","first-page":"e2420579","DOI":"10.1001\/jamanetworkopen.2024.20579","article-title":"Pediatric Complex Chronic Condition System version 3","volume":"7","author":"Feinstein","year":"2024","journal-title":"JAMA Netw Open."},{"key":"2026091620024432700_r21","first-page":"36","volume-title":"Emergency Severity Index (ESI) Implementation Handbook: A Triage Tool for Emergency Department Care, Version 5","author":"Wolf","year":"2023","edition":"2023 ed"},{"issue":"1","key":"2026091620024432700_r22","doi-asserted-by":"crossref","first-page":"20","DOI":"10.1037\/met0000182","article-title":"Fixed effects models versus mixed effects models for clustered data: reviewing the approaches, disentangling the differences, and making recommendations","volume":"24","author":"McNeish","year":"2019","journal-title":"Psychol Methods."},{"key":"2026091620024432700_r23","doi-asserted-by":"crossref","first-page":"130","DOI":"10.1016\/j.ajem.2023.09.054","article-title":"Delays in treatment and disposition attributable to undertriage of pediatric emergency medicine patients","volume":"74","author":"Berkowitz","year":"2023","journal-title":"Am J Emerg Med."},{"issue":"6","key":"2026091620024432700_r24","doi-asserted-by":"crossref","first-page":"e2022059386","DOI":"10.1542\/peds.2022-059386","article-title":"Undertriage for children with caregivers preferring languages other than English","volume":"151","author":"Rojas","year":"2023","journal-title":"Pediatrics."},{"issue":"1","key":"2026091620024432700_r25","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1542\/hpeds.2024-008063","article-title":"Pediatric triage accuracy in pediatric and general emergency departments","volume":"15","author":"Geanacopoulos","year":"2025","journal-title":"Hosp Pediatr."},{"key":"2026091620024432700_r26","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1016\/j.jbi.2017.07.012","article-title":"Natural language processing systems for capturing and standardizing unstructured clinical information: a systematic review","volume":"73","author":"Kreimeyer","year":"2017","journal-title":"J Biomed Inform."},{"issue":"4","key":"2026091620024432700_r27","doi-asserted-by":"crossref","first-page":"1051","DOI":"10.4338\/ACI-2016-08-RA-0129","article-title":"Identification of long bone fractures in radiology reports using natural language processing to support healthcare quality improvement","volume":"7","author":"Grundmeier","year":"2016","journal-title":"Appl Clin Inform."},{"issue":"3","key":"2026091620024432700_r28","doi-asserted-by":"crossref","first-page":"275","DOI":"10.1016\/j.ajem.2008.11.021","article-title":"Practice variation in the management for nontraumatic pediatric patients in the ED","volume":"28","author":"Chang","year":"2010","journal-title":"Am J Emerg Med."},{"key":"2026091620024432700_r29","article-title":"Practice pattern variation in test ordering for low-acuity pediatric emergency department patients","author":"Doctor","journal-title":"Pediatr Emerg Care."},{"key":"2026091620024432700_r30","doi-asserted-by":"crossref","first-page":"100015","DOI":"10.1016\/j.hfh.2022.100015","article-title":"The effect of emergency department nurse experience on triage decision making","volume":"2","author":"Levis-Elmelech","year":"2022","journal-title":"Human Factors in Healthcare."},{"issue":"15","key":"2026091620024432700_r31","doi-asserted-by":"crossref","first-page":"1","DOI":"10.3310\/hta16150","article-title":"Systematic review and validation of prediction rules for identifying children with serious infections in emergency departments and urgent-access primary care","volume":"16","author":"Thompson","year":"2012","journal-title":"Health Technol Assess."},{"key":"2026091620024432700_r32"},{"issue":"8","key":"2026091620024432700_r33","doi-asserted-by":"crossref","first-page":"4138","DOI":"10.3390\/ijerph18084138","article-title":"Social-ecological barriers to access to healthcare for adolescents: a scoping review","volume":"18","author":"Garney","year":"2021","journal-title":"Int J Environ Res Public Health."},{"issue":"3","key":"2026091620024432700_r34","doi-asserted-by":"crossref","first-page":"734","DOI":"10.1177\/13674935241239837","article-title":"Adolescents\u2019 perspectives and experiences of accessing general practitioner services: a systematic review","volume":"29","author":"Lawrence","year":"2025","journal-title":"J Child Health Care."},{"issue":"7","key":"2026091620024432700_r35","doi-asserted-by":"crossref","first-page":"e94","DOI":"10.1097\/PEC.0000000000003130","article-title":"Pediatric emergency physicians\u2019 knowledge, attitudes, and behaviors regarding confidential adolescent care","volume":"40","author":"Gutman","year":"2024","journal-title":"Pediatr Emerg Care."},{"issue":"6","key":"2026091620024432700_r36","first-page":"e40814","article-title":"Assessing the gap in adolescent emergency care training for emergency medicine residents: a systematic review","volume":"15","author":"Williams","year":"2023","journal-title":"Cureus."},{"issue":"2","key":"2026091620024432700_r37","doi-asserted-by":"crossref","first-page":"245","DOI":"10.1017\/cem.2019.458","article-title":"Patient race, ethnicity, and care in the emergency department: A scoping review","volume":"22","author":"Owens","year":"2020","journal-title":"CJEM."},{"issue":"6","key":"2026091620024432700_r38","doi-asserted-by":"crossref","first-page":"795","DOI":"10.1016\/j.jacr.2020.12.016","article-title":"Patient race\/ethnicity and diagnostic imaging utilization in the emergency department: a systematic review","volume":"18","author":"Shan","year":"2021","journal-title":"J Am Coll Radiol."},{"issue":"8","key":"2026091620024432700_r39","doi-asserted-by":"crossref","first-page":"801","DOI":"10.1111\/j.1553-2712.2010.00823.x","article-title":"Racial and sex differences in emergency department triage assessment and test ordering for chest pain, 1997\u20132006","volume":"17","author":"L\u00f3pez","year":"2010","journal-title":"Acad Emerg Med."},{"issue":"5","key":"2026091620024432700_r40","doi-asserted-by":"crossref","first-page":"491","DOI":"10.1016\/j.jen.2011.01.016","article-title":"Under-triage as a significant factor affecting transfer time between the emergency department and the intensive care unit","volume":"37","author":"Yurkova","year":"2011","journal-title":"J Emerg Nurs."},{"issue":"1","key":"2026091620024432700_r41","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1016\/j.annemergmed.2022.08.010","article-title":"A quality framework to address racial and ethnic disparities in emergency department care","volume":"81","author":"Khidir","year":"2023","journal-title":"Ann Emerg Med."},{"issue":"5","key":"2026091620024432700_r42","doi-asserted-by":"crossref","first-page":"888","DOI":"10.5811\/WESTJEM.59044","article-title":"Racial differences in triage for emergency department patients with subjective chief complaints","volume":"24","author":"Peitzman","year":"2023","journal-title":"West J Emerg Med."},{"issue":"2","key":"2026091620024432700_r43","doi-asserted-by":"crossref","first-page":"e556","DOI":"10.1097\/PEC.0000000000002439","article-title":"Racial and language disparities in pediatric emergency department triage","volume":"38","author":"Metzger","year":"2022","journal-title":"Pediatr Emerg Care."},{"issue":"2","key":"2026091620024432700_r44","doi-asserted-by":"crossref","first-page":"225","DOI":"10.5811\/westjem.2020.9.48431","article-title":"Language barriers and timely analgesia for long bone fractures in a pediatric emergency department","volume":"22","author":"Gaba","year":"2021","journal-title":"West J Emerg Med."},{"issue":"4","key":"2026091620024432700_r45","doi-asserted-by":"crossref","first-page":"e12477","DOI":"10.1002\/emp2.12477","article-title":"Effect of language interpretation modality on throughput and mortality for critical care patients: a retrospective observational study","volume":"2","author":"Oca","year":"2021","journal-title":"J Am Coll Emerg Physicians Open."},{"issue":"11","key":"2026091620024432700_r46","doi-asserted-by":"crossref","first-page":"3532","DOI":"10.1007\/s11606-021-06823-4","article-title":"Addressing gaps in interpreter use: time for implementation science informed multi-level interventions","volume":"36","author":"Khoong","year":"2021","journal-title":"J Gen Intern Med."},{"issue":"6","key":"2026091620024432700_r47","doi-asserted-by":"crossref","first-page":"e2319438","DOI":"10.1001\/jamanetworkopen.2023.19438","article-title":"Patterns in patient encounters and emergency department capacity in California, 2011\u20132021","volume":"6","author":"Hsia","year":"2023","journal-title":"JAMA Netw Open."},{"issue":"4","key":"2026091620024432700_r48","doi-asserted-by":"crossref","first-page":"e250417","DOI":"10.1001\/jamahealthforum.2025.0417","article-title":"Emergency care access based on a proposed CMS National Quality Measure","volume":"6","author":"Sangal","year":"2025","journal-title":"JAMA Health Forum."},{"issue":"9","key":"2026091620024432700_r49","doi-asserted-by":"crossref","first-page":"641","DOI":"10.1097\/PEC.0b013e31814a69e2","article-title":"Development of a novel measure of overcrowding in a pediatric emergency department","volume":"23","author":"Weiss","year":"2007","journal-title":"Pediatr Emerg Care."},{"issue":"3","key":"2026091620024432700_r50","doi-asserted-by":"crossref","first-page":"258","DOI":"10.1016\/j.jen.2017.06.010","article-title":"Triaging the emergency department, not the patient: United States emergency nurses\u2019 experience of the triage process","volume":"44","author":"Wolf","year":"2018","journal-title":"J Emerg Nurs."},{"issue":"6","key":"2026091620024432700_r51","doi-asserted-by":"crossref","first-page":"496","DOI":"10.1016\/j.jen.2015.04.016","article-title":"ED triage decision-making with mental health presentations: a \u201cthink aloud\u201d study","volume":"41","author":"Clarke","year":"2015","journal-title":"J Emerg Nurs."},{"issue":"5","key":"2026091620024432700_r52","doi-asserted-by":"crossref","first-page":"396","DOI":"10.1016\/j.jen.2015.02.003","article-title":"Clinical decision making in triage: an integrative review","volume":"41","author":"Stanfield","year":"2015","journal-title":"J Emerg Nurs."},{"issue":"10087","key":"2026091620024432700_r53","doi-asserted-by":"crossref","first-page":"2393","DOI":"10.1016\/S0140-6736(17)30555-X","article-title":"Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study","volume":"389","author":"Babl","year":"2017","journal-title":"Lancet."}],"container-title":["Hospital Pediatrics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/publications.aap.org\/hospitalpediatrics\/article-pdf\/doi\/10.1542\/hpeds.2026-009554\/1964213\/hosppeds.2026009554.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/publications.aap.org\/hospitalpediatrics\/article-pdf\/doi\/10.1542\/hpeds.2026-009554\/1964213\/hosppeds.2026009554.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,17]],"date-time":"2026-09-17T00:02:53Z","timestamp":1789603373000},"score":1,"resource":{"primary":{"URL":"https:\/\/publications.aap.org\/hospitalpediatrics\/article\/doi\/10.1542\/hpeds.2026-009554\/209481\/Accuracy-and-Disparities-in-Pediatric-Emergency"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,17]]},"references-count":53,"URL":"https:\/\/doi.org\/10.1542\/hpeds.2026-009554","relation":{},"ISSN":["2154-1663","2154-1671"],"issn-type":[{"value":"2154-1663","type":"print"},{"value":"2154-1671","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,17]]},"article-number":"e2026009554"}}