Which emergency department a child reaches in crisis varied by ethnicity and diagnosis

Design

retrospective cross-sectional study of a national administrative sample, multivariable logistic regression

Population

5,369,821 weighted US emergency visits by children aged 5–17 with a primary mental health diagnosis, 2016–2022

Primary outcome

presentation to an emergency department with high annual paediatric volume

Effect

adjusted OR 1.19 (95% CI 1.05–1.35) for non-Hispanic Black and 0.54 (0.35–0.83) for Native American children

Paediatric mental health presentations to emergency departments are rising, and where they land determines what is available — a high-volume paediatric department has resources a low-volume one does not. This cross-sectional study used the US Nationwide Emergency Department Sample for 2016 to 2022, identifying 5,369,821 weighted visits by children aged 5 to 17 with a primary mental health diagnosis.

Half of those visits (50.1%) were to departments with high annual paediatric volume, defined as 10,000 visits or more; 4.7% were to low-volume departments. After adjustment, non-Hispanic Black children had higher odds of presenting to a high-volume department than non-Hispanic White children (1.19, 95% CI 1.05 to 1.35), and Native American children had substantially lower odds (0.54, 0.35 to 0.83). Children with substance-related diagnoses had lower odds than those presenting with suicide or self-injury (0.79, 0.71 to 0.87).

The Native American finding is the one that should hold a reader's attention: roughly half the odds of reaching a department equipped for paediatric mental health, in a group with well-documented excess suicide risk. This is US data and the volume categories do not transfer to Indian practice, but the structural point does — where a child in crisis is brought is not random, and the departments least equipped for them are disproportionately serving the children with least access elsewhere.

• Know what paediatric mental health support your department can actually access out of hours
• Do not assume a transfer pathway exists because a specialist service exists somewhere
• Record the presenting diagnosis precisely — substance-related and self-injury presentations followed different routes
• Audit where your own paediatric mental health presentations are coming from and where they go
• Treat a low-volume department's first such presentation of the month as the one most likely to go wrong

Why it matters

The children least likely to reach a well-resourced department are the ones already least served everywhere else.

Don't overread it

This is administrative coding data describing where visits occurred — it says nothing about the care those children received.

The statistics, in plain English

These are adjusted odds of reaching a high-volume department, not risks of anything clinical, so a ratio of 0.54 means about half the odds of arriving somewhere better resourced. The interval for Native American children runs from 0.35 to 0.83, which is wide because the group is small in a national sample — the direction is clear, the magnitude less so. Weighted national estimates like 5.37 million visits are extrapolations from a sample, and carry their own uncertainty that the odds ratios do not display.

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