COE4CCN Mental Health Measures Data Abstraction Tool
GENERAL GUIDELINES
1. Abstraction Form – This abstraction form collects data for six quality measures
applying to children or adolescents with selected mental health conditions treated in
the emergency department (ED) or as an inpatient. The conditions of interest for
children (5 to 11 years of age) and adolescents (12 to 19 years of age) are
dangerous self-harm and suicidal ideation and psychosis. Cases are selected for
abstraction based on specifications including age at the time of admission, site of
care (ED and/or inpatient), and discharge-related ICD-9 codes. (See separate
specifications for case selection.) Cases are assigned to just one condition of
interest for abstraction.
2. Site of Care – The quality measures are specific to the site of care. Therefore, not all
measures for a particular condition may apply to the case being abstracted for a
particular condition.
3. Exclusions – There are some conditions or circumstances that would exclude a
patient from being included in a quality measure. For the most part, these patients
will be excluded in an automated fashion based on administrative data codes and
other parameters during the sample selection. However, if additional data collected
in the abstraction indicate that the case is to be excluded, the abstraction tool will
display this information.
4. Quality Measures – The quality measures included in the abstraction tool are the
following:
Measure
number
Measure
MH Quality Measure for Children/Adolescents Presenting with Danger to Self and
Suicidality (Applies to children/adolescents ≥5 years-old - ≤19 years-old)
DSD9
Children/adolescents admitted to the hospital for dangerous self-harm
or suicidality should have documentation in the hospital record of
discussion between the hospital provider and the patient's outpatient
provider regarding the plan for follow-up (discussion can be by phone
or email).
MH Quality Measures for Children/Adolescents Presenting with Psychosis (Apply to
children/adolescents ≥5 years-old – ≤19 years-old)
P2
P3
All children/adolescents who present to the ED with psychotic
symptoms should receive the following screening laboratory tests:
a) Urine drug screening
b) Serum alcohol screening
All children/adolescents admitted to the hospital with psychotic
symptoms should have a psychiatric consult (in person or by
telepsychiatry) within 24 hours of admission.
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CLINICAL GUIDELINES
The mental health module focuses on two conditions and looks at both ED and inpatient
care, as indicated. The conditions of interest for children (5 to 11 years of age) and
adolescents (12 to 19 years of age) are dangerous self-harm/suicidal ideation and
psychosis.
1. Date of Birth – Enter the patient’s date of birth.
2. Condition of Interest – Select the condition that was designated for this emergency
department/inpatient admission from the denominator specified age categories and
ICD-9 codes.
3. Place of Care – Distinguish among patients who were seen in the ED of the marker
hospital (either exclusively or before admission to the marker hospital) and those
who were admitted directly to the marker hospital. Response 3 includes patients
admitted directly to the marker hospital who may have been seen in a different ED or
hospital prior to admission, but were NOT treated in the marker hospital’s ED.
4. Date of ED Admission – For those patients seen in the marker ED, enter the date of
the admission to the ED.
5. Dates of Admission and Discharge – For those patients admitted to the marker
hospital (either via the marker ED or directly), give the dates and times of the
hospital admission and discharge. Do not include any time spent in the ED.
6. This item has been deleted.
7. This item has been deleted.
8. Discharge Disposition – [Module: Dangerous self-harm/suicidal ideation, inpatient
care] Indicate the patient’s disposition at discharge. If the patient was transferred to
an acute or non-acute inpatient facility other than the marker hospital, select
response 1. This case will be excluded since care continued at that institution.
Response 2 includes patients who left AMA or who eloped. Response 3 is for
patients who were discharged to some sort of holding facility such as jail, juvenile
detention, or other holding placement. Response 4 is for patients who were
discharged to half- or partial-hospitalization. The definition of this varies among sites,
but in general indicates an arrangement where the patient is at home at night, but in
a therapeutic environment during the day. Response 5 is for patients who were
discharged to home, which includes a foster home or other group homelike
arrangement.
9. Follow-up MD – [Module: Dangerous self-harm/suicidal ideation, inpatient care]
Indicate “1” if at the time of discharge, the patient had a designated primary care
provider (PCP) or psychiatrist who would manage the patient’s care post-discharge.
Even patients with no known provider at the time of hospital admission should have
been referred to a follow-up provider who was a PCP or a psychiatrist at the time of
discharge. Indicate “2” if there is no follow-up provider identified.
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10. Follow-up MD: SI Plan – [Module: Dangerous self-harm/suicidal ideation, inpatient
care] Indicate “1” if the hospital provider communicated (by telephone or email) with
the follow-up provider (PCP or psychiatrist) during the time window of 24 hours prior
to discharge to 48 hours after discharge. The window of time is computed based on
the discharge date and time and is displayed within the question text in the data
collection tool. The purpose of this communication is to be sure a safe transition is in
place, as this item applies only to patients hospitalized for self-harm/suicidal ideation.
Select response “2” if the hospital provider is also the follow-up outpatient provider
OR if outpatient care has been arranged to be continued in the marker hospital's own
psychiatric outpatient clinic. The latter arrangement is considered to be an adequate
communication of the safety plan for the patient. If you cannot verify that there was
any communication between the hospital provider and the follow-up PCP/psychiatrist
AND there is no same-institution psychiatric clinic follow-up arranged, select
response “3” (Neither of the above/No data).
11. Urine Drug Screening /Serum Alcohol Screening – [Module: Psychosis, ED care]
This item applies to children and adolescents presenting with psychotic symptoms
who were admitted to the marker ED. Indicate if the patient had a urine drug screen
or serum alcohol screen while in the ED. The alcohol test will be a separate test
from the drug tests. The drug test must be comprehensive in that it tests for multiple
types of illicit drugs. Do NOT give credit for tests that include results of just a single
drug. Drug screens commonly include tests for benzodiazepines, barbiturates,
methamphetamine, cocaine, methadone, opiates, tetrahydrocannabinol, etc.
12. Psychiatric Consult – [Module: Psychosis, inpatient care] Indicate if the patient had a
psychiatric consult within 24 hours of admission. The end of the 24-hour time frame
will be computed (based on admission time) and displayed. Include in this interval
any psychiatric consult that may have been done in the marker ED prior to admission
if the patient was admitted via the marker ED. The consult may be in person or by
telemedicine. The consult must have been done by a psychiatrist or PhD
psychologist. If the consult was done by a clinician-extender (nurse practitioner,
advanced practice nurse, physician assistant, licensed social worker, or licensed
counselor), this is acceptable as long as the assessment is co-signed by a
psychiatrist. If an appropriate person did not assess the patient during the first 24
hours, choose response 2 (No/No data), and continue to Q12a).
12a) Indicate if the patient had a psychiatric consult within 48 hours of admission.
(The end of this time frame is computed based on the date and time of admission will
be displayed in the question text.) If a qualifying MH provider assessed the patient
by the indicated time, select response 1 only if a justification was noted for the delay
that prevented the consult from occurring within the first 24 hours. The abstractor is
not asked to evaluate the content or acceptability of the justification. Any justification
that specifically refers to the time delay for the assessment is acceptable. If there is
no justification noted for the delay, select response 2. If the consult did not occur or
only occurred more than 48 hours after admission, select response 3 (Neither of the
above/No data).
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