1. Guidelines for MPUS should be driven by/created together with nursing and be tailored to local needs/regulations (medicine and psychiatry reimbursement and regulations vary by state and county!)
2. Essential to realize that patients on MPUs have a higher level of complexity (not just 2 diseases, more than comorbidity)
3. MPUs are more than med + psych they are places to address the biopsychosocial/whole patient
4. MPUs work best when they have tailored/individualized approaches rather than inflexible protocols
5. MPUs work best when clinicians have venues for communication / there are routine interdisciplinary meetings with focus on discharge (MASH acronym, documents describing rounds)
Silos, lack of continuity, frequent changes of rooms/services, too many services
Behaviorally difficult patients is a top-cited reason for nursing turnover (reference). Violence (physical, hate speech) against healthcare workers widely recognized, but largely unaddressed aspect of healthcare profession.
1:1 observer cost is high, MPUs reduce that (we need data to reference!). Also "lost productivity" - i.e. delay in treatments (uncooperative, lack of/uncertainty about decisional capacity), suboptimal treatment, lines/tubes being pulled and needing replacement.
Pursue demand data / demographic data (# of psych consults, hours of 1:1 used, LOS of patients with psychiatric diagnoses vs without, # behavioral codes, staff injuries). Also staff surveys - eg staff job satisfaction.
Medical unit regulations
Psychiatric unit regulations
How to mesh those
Vary by state, obviously.
New York State Office of Mental Health guidelines
Designing an MPU can be challenging due to the need to balance medical utility, patient and staff safety, applicable federal and state regulations, consistency with other hospital units, and maintaining a pleasant, therapeutic environment. We recommend an interdisciplinary design team comprised at least of administrators, physicians, nursing staff (esp psychiatric nursing staff), and architects. In addition, formation of a safety committee can help maintain an ongoing vigilance and dedication toward staff and patient safety.
The MPU may contain the following in addition to patient rooms:
The New York State Office of Mental Health has a detailed guide on furnishings and fixtures specifically designed for safety considerations. Architects may also be able to customize furnishings (such as bedside cabinetry). This guide can be found here:
New York State Office of Mental Health manual with details on unit equipment
Furniture
Patient room doors - open both directions to prevent barricading. Typically opens into the room; alarms if opened into hallway (i.e. patient burst outward). Contain weight sensor alarms to prevent someone from hanging from the door. Doors to conference room, exam room, staff bathroom, medication room are locked by badge/key access.
Plumbing fixtures & bathrooms - Built into sink/shower to prevent use as a ligature point. Timed faucets to prevent flooding. Shower or faucet can be turned off from nursing station to prevent flooding/excessive use. Bathroom doors can be locked by staff in cases of polydipsia or purging behavior.
Gases / Medical Equipment - contains oxygen, air, suction outlets, and scaffolding for orthopedic needs. Tubing is removed by default and installed only when necessary for use. Orthopedic fixtures are only installed onto scaffolding as necessary. Telemetry packs available, but not in room by default. IV poles on wheeled mounts, removed from room if not in use.
Hand sanitizer dispensers - Consider using only portable containers instead of wall-mounted dispensers. If using wall-mounted dispensers, ensure that they can be emptied to prevent patient consumption of hand sanitizer if necessary.
Personal duress alarms available to all staff members - can be used to trigger behavioral code.
Panel mounted in each room for Code Blue, Behavioral Code - can be turned off remotely in case of abuse.
Video camera monitoring in each patient room and public areas (not bathrooms) - monitored from nursing work area. If unit is locked, consent for video monitoring can be included with consent for admission. Video monitoring can be used as a means of ensuring safety while still having necessary medical equipment and fixtures available in patient rooms.
Unit photos from University Hospitals (Case Western)
Video monitoring protocols from University Hospitals (Case Western)
More sample photos from existing MPUs forthcoming...
Dual-trained physician or integrated team of hospitalist + psychiatrist, +/- APPs, residents, medical students.
5:1 nursing ratio. Nurses generally work 8 or 12 hour shifts, but staff can change at the following times: 07:00, 11:00, 15:00, 19:00, 23:00. Additional staff, if needed, arrive at these times. Each RN assigned an NA +/- nursing student.
Spiritual services (consultation), security officer (called as needed).
Nurse manager + assistant nurse manager. One of the three floor RNs is charge nurse for the shift.
??? - one example is a nursing in-service for CME, where MPU staff give a presentation.
Typical team for 15 bed MPU, locked unit with full psychiatric services:
Typical staffing for 10 bed MPU:
BLS, ACLS.
BLS, ACLS. Typically recruited from med/surg nurses and given additional psychiatric training. Rare to recruit psychiatric nurse and give medical training.
Challenging, partly due to complexity/acuity of patients. Often MPU nurses promoted to nurse manager, transition to NP school.
Will require training in psychiatric aspects, mainly legal considerations, precautions, activity restrictions, levels of care at discharge, ECT considerations (eg diet, medication timing, frequency), heavier utilization of nurses, NAs, and other unit staff as frontline observers/collateral informants, higher emphasis on sleep hours, PO intake, clozapine ordering.
Will require training in medical aspects of care, such as concrete actions of placing enteral tubing, ordering medical cares in the EMR, discharging home with antibiotics, systems considerations for imaging and specialist consultations (eg availability during evenings/weekends, need for NPO status), antibiotic choice and dosing, etc.
07:00 - Day team arrives, receives signout from night float. Review charts, pre-round. Night float presents overnight admits.
08:00 - Interdisciplinary meeting (see below).
~08:30-09:00 - Begin rounding on patients. May need to interrupt rounding for commitment hearings.
12:00 - Noon conference
Afternoon - Prioritize filing court reports early. Resident lectures, discussion of various topics with students, revisit patients, calls/meetings with family/consultants.
17:00 - Signout to night float.
Notes: Additional meetings with nursing, SW (formal and informal) throughout day as needed. Admissions usually happen in afternoons due to workflow of ED, ICU, psych consult, and hospital admin.
Use language from the UR Intern packet
Orientation for interns from University of Rochester
Orientation for non-psychiatric residents from University of Iowa
Orientation for psychiatric residents from University of Iowa
-If not done specifically by MPU staff, be sure that triage officer is familiar with admission criteria (eg give a lecture to the ED residents/staff about your admission criteria).
-Often also gated by psych consult team for transfers from other areas of the hospital.
-Due to complex nature of patients, flexibility and openness to negotiation (with other services) is essential. Most admissions can be justified with "we'll take better care of them on the MPU" mentality to suppress personal bile.
Maybe you are OK with this, maybe you are not.
-Acute medical problem requiring hospitalization + acute psychiatric problem requiring hospitalization
-Acute medical problem requiring hospitalization + behavioral disturbance interfering with that care (due to delirium, chronic mental illness, intellectual disability, dementia, etc).
-Heavy utilizers well known to MPU, who tend to be disruptive on other units (medical or psychiatric).
-These patients are likely to have personality and/or cognitive disorders, and consistency of the MPU can be of substantial benefit.
-Medical inpatients with chronic mental illness that is stable.
-Medical inpatients who are willfully rude or disruptive (eg due to personality disorder, ie "patient is mean").
-Cognitive deficit that does not interfere with medical care (eg intellectual disability but without new behavioral problems).
-Chronic medical illness that could be treated as an outpatient, therefore can be treated on general psychiatry unit (eg COPD stable on home O2).
-Once a patient is admitted, it is extremely unlikely they will be accepted for transfer back to a general med/surg unit during the admission.
University of Rochester
University Hospitals (Case Western)
St. Charles Parish Hospital (Tulane)
Interdisciplinary Communication is critical for safe and effective patient care in a Med Psych Unit. The need for careful attention to communication is driven by the complexity of the patients and their diagnoses, the multiple team members usually caring for the same patient, and the juxtaposition of two different cultures of practice. There should be clear opportunities and strategies for both regular, scheduled communication, and ad hoc, as needed communication. A common strategy for communication combines regular (daily or more) brief meetings, often described as huddles, with weekly comprehensive meetings, which may be longer and include a wider range of disciplines. There must also be a way for team members to communicate in real-time. This could take the form of secure texting or local 2-way technology (such as Vocera). These can be more effective than pagers, especially to transmit brief or urgent information rapidly and efficiently. Critical to the functioning of any team, but more important with brief communications, is understanding each person’s role and clear assignment of responsibilities. For instance, discussing the need for a mental health follow up in huddle is insufficient-- it must be clear whose responsibility it is to schedule and in what time frame.
Common topics covered in regularly scheduled meetings include the following:
Staff who may be involved in the regularly scheduled meetings include:
Another important tool often used in a Med Psych Unit to ensure good information-sharing is a white board or dry erase board that can include key information about each patient. The daily huddles can be conducted proximate to this board and information updated daily. An example might be:
| Rm 4015 | John Smith | anticipated discharge to home | No safety concerns |
| Rm 4016 | Amy Jones | anticipated discharge to psychiatric hospital | SI/sitter |
Checklist for interdisciplinary meetings from University of Rochester
Recommend proximity of LIP work room to unit for ease of nursing access. Can be double-edged if LIPs conducting resident/student education, presenting a new admit, etc. Recommend use of 2-way asynchronous communication technology that is HIPAA-compliant (Vocera, Voalte). Phones are synchronous, forces both parties to be available during the call. Pagers are 1-way, forces sender to remain stationary awaiting call back after sending page. Also recommend use of EMR and/or physical space (eg whiteboard) to designate which LIP, nurse, SW is caring for each patient each day so they can find each other.
Consider additional huddle between LIPs and nursing for more detailed presentation of nursing reports/observations, ability to clarify/correct orders.
Use written documents (usually incorporated into EMR) to sign out between shifts.
Upon admission, patient will be changed into a hospital gown and searched. All belongings will be catalogued. Valuables (cash, jewelry) will be secured by hospital security. Other belongings will be locked into cabinet in patient room. After admission, patient may be allowed to wear their own clothing (street clothes) at discretion of MPU team.
Patient belongings protocol from University Hospitals (Case Western)
Will initially be locked with belongings. Patients may be allowed to use their cell phones at MPU team discretion, provided they agree not to take photographs with the phone while on the unit. A privacy sticker is placed over phone cameras to help mitigate this. Chargers will be secured in nursing station due to ligature risk. Patients may hand their phones to nursing staff for charging.
Beyond H&P performed by LIP team, patient will have RN assessment upon arrival to unit. This assessment will focus on HPI and safety concerns related to precautions, eg "have you ever had sex in the hospital?"
[Link to patient assessment questions from various hospitals]
If a patient is deemed at risk (eg violence, foreign body ingestion), a finger-foods only diet may be ordered that includes no utensils.
Not sure what to say on this that isn't covered elsewhere?
Suicide, self-harm - Patient may not have clothing involving drawstrings or cords (eg cords in sweat shirts, sweat pants, shoelaces, belts). Patients may not have sharp objects (eg shaving razors) unless directly supervised by nursing staff while in use. Determined by HPI, observed behavior on unit. Must be discontinued to qualify for off-unit activities and prior to discharge. For extreme risk, paper gowns are available.
General behavioral Precautions from University Hospitals (Case Western)
Suicide Precautions from University Hospitals (Case Western)
Elopement - Patient may not wear street clothes, may not have shoes. Situations warranting elopement precautions - involuntary hospitalization involving strife with patient, patient observed waiting around unit doors or trying door handles. Must be discontinued to qualify for off-unit activities (not including medical tests eg imaging).
Elopement Precautions from University Hospitals (Case Western)
Violence / Assault - ??? Patient must be in a single room. Patient is restricted from participating in unit activities.
Assault Precautions from University Hospitals (Case Western)
Sexual acting out - ??? informational only?
Withdrawal - informational only? Monitoring (eg more frequent vitals) and medications (eg PRN BZDs) ordered separately.
Seizure - Patient bed is lowered to ground level.
Wandering - informational only? Staff may create large signs to post on the patient's door, eg "John's Room" to help orient patient.
Foreign body ingestion - Patient
Fire - ??? informational only?
Room restrict - Patient must remain in room.
Supervised 1:1 - Patient must have a 1:1 observer with them at all times.
Restrict - Patient must remain on unit, but can participate in unit activities.
Level 1 - Patient may participate in unit activities that take place in the hospital.
Level 2 - Patient may participate in unit activities outside but near the hospital.
Level 3 - Patient may participate in activities within 25 miles of the hospital. Patient may take a therapeutic leave of absence from the hospital if accompanied at all times by a responsible adult who agrees to supervise them during the entirety of the leave. Usually only for voluntary patients.
If patient leaves the unit for a medical test or procedure, they must be accompanied by RN or NA. Occasionally, a patient is allowed to leave the unit to attend an activity on another unit; generally, this has been for patients wishing to participate in dialectic behavior therapy groups held on the general psychiatry unit, or spiritual services held on the general psychiatry unit. Nursing personnel escorts the patient to this other unit.
Visitors must sign in with nursing staff and lock their belongings in hospital lockers prior to entering the unit. Children under age 18 are not allowed. Outside food/drink are allowed but must first be inspected by nursing staff. On rare occasions, visitors may be allowed to stay in the patient's room overnight if the patient has a private room. This is generally reserved for cases such as parents of patients with communication difficulties and/or intellectual disability.
Visitor policy from University Hospitals (Case Western)
Eating disorders - our inpatient eating disorders unit has strict protocols for meals, snacks, and unit activities. We try to adhere to these policies on the MPU, but MPU does not have this structure as firmly in place and so this is often difficult to enforce. As such, MPU has usually focused on medical stability and expeditious transfer to inpatient eating disorder service.
Postpartum - Postpartum patients are often escorted by nursing personnel to the nursery to be able to visit their newborns.
Specialty medical clinics - Some specialty services (eg ophthalmology, dermatology, chemotherapy infusion, dialysis) request inpatients to travel to their clinics for examination/treatment due to need for specialty equipment. In these cases, MPU nursing personnel escort the patient to their clinic visit, which may necessitate additional nursing staffing during those times.
Long-term IV antibiotic needs - Usually, someone in need of long term IV antibiotics (eg osteomyelitis, endocarditis) can have a PICC placed and discharged. This becomes more complicated in a patient with a history of IV drug use. PICC teams have become more hesitant to place PICCs in this patient group due to fears of abuse potential and liability. If a psychiatrist assessment can be made that the risk of PICC abuse for IVDU is low, the PICC team may be willing, especially if the drug use history is remote. However, in many cases, especially with current IV drug use, PICC teams will refuse this service. Patients in this situation may find they need to remain inpatient for the duration of their antibiotic course.
These are written via a collaboration between LIPs and nursing staff to target specific disruptive behaviors of specific patients. These generally detail patient privileges that can be earned or revoked based on behavior (eg TV use, phone use, limiting nursing requests to Q1hr, etc).
Wrist restraints
4-point restraints
Twice-as-toughs
Spit mask - a mesh mask to prevent patients from spitting on staff.
Seclusion rooms - a bare room for seclusion of extremely agitated/violent patients. Patients are placed in the room with only a mattress and clothing. A member of the nursing staff is observing at all times. There is no bathroom in the seclusion room, so the patient will need to be escorted out to use the restroom.
Netbed - essentially a box with mesh walls that is attached to a bed. Patient is placed inside and then the netbed is zipped shut. Only for extremely unsafe patients.
Note that behavioral restraints must be continually assessed for need, and have a maximum duration of 4 hours before LIP must renew order. Medical restraints may be used for up to 24 hours before order must be renewed.
For behavioral codes occurring on the MPU (or on a general psychiatry unit), all unit RNs and NAs respond, as well as LIPs. Hospital security is notified and also respond (obviously it takes them longer to arrive). For behavioral codes occurring anywhere else in the hospital, one NA from each psychiatric unit responds, carrying a pack with supplies (eg restraints), the SWOT (service without territory) nurses respond, the originating unit's nursing staff, the patient's primary team, hospital security, and the psych consult team also respond.
Evaluates patients for mobility needs, provides rehabilitation exercises, makes recommendations for discharge level of care. Often reveals if patients lack motivation.
Conducts therapeutic groups. Can perform formal Allen testing to evaluate cognition/daily function and make recommendations for discharge level of care. Patient behavior in group often informative as to cognitive status, ability to socialize and interact with others. Also provides meal planning, cooking activities for patients with eating disorders.
Provides social interaction and recreational activities to patients. Includes recreational activities that patients can enjoy alone (puzzles, coloring books) and interactive activities (crafts, games, cards). Often provides an informal assessment of patient function, cognition, and social interactions. Due to medical illness, participation in groups is often much lower than on a general psychiatry unit, so RT helps provide diversion for the patients who are more medically stable.
Evaluates patients for malnutrition. Can perform calorie counts. Makes recommendations for dietary supplements (eg protein drinks) or enteral feeding (either as sole source of nutrients or as supplement to PO intake). Provides recommendations for graded caloric intake for initial treatment of newly admitted patients with eating disorders.
Consulted as part of otolaryngology. Evaluates dysphagia/swallow safety, teaches patients exercises and techniques for safer swallowing and reducing aspiration, makes recommendation on consistencies of solid and liquid intake.
Consulted separately as needed. Addresses pressure ulcers, ostomies, and other wounds, including surgical wounds.
In addition to performing for patients, can lend musical instruments to patients who play and/or are interested in learning.
Available with a variety of denominations. Be certain to discuss with spiritual services appropriateness of consult re: hyperreligiosity/delusions secondary to mental illness.
Consult service. Helpful for discussing goals of care, end-of-life discussions, as well as for patients with chronic, intractable conditions that negatively affect their quality of life.
Available as a consult service. Typically outpatient consultations are preferred due to length of comprehensive testing and desire to test patient at a stable baseline instead of surrounding an acute illness. However, if cognitive assessment is required for discharge planning, inpatient consult can be warranted.
Focus on the whole patient and their comprehensive care. Utilize any and all assessments and metrics, objective and subjective, to make a best determination on appropriate level of care after discharge and follow-up care (PCP + psychiatrist vs integrated clinic, specialists). After weighing all factors listed below, consider also the patient's stated wishes and long-term personality. Many patients have poor psychosocial support or unstable housing; conventional thinking would hold these factors too risky for discharge. However, it is essential to consider the patient's lifestyle prior to hospitalization and goals of care. We should practice radical acceptance of some of these factors if consistent with patients' stated wishes. Often, when faced with a strenuous argument from a patient valuing autonomy and independence, the patient should be given one or more "chances to fail" before involuntary commitment to a care facility. Collateral information from the patient's family/friends is valuable for weighing such decisions.
Important to think about how we do discharge differently than other straight medicine or psychiatry units
[Look at Wittink, Jackson IMIPS paper where we have language and a model for meetings focused on discharge]
-Patient's stated wishes.
-Mobility concerns / needs - assessed by PT.
-Cognitive impairments - assessed by Allen testing (OT), neuropsychological testing, informed by history (eg not caring for self in community prior to hospitalization). Some subjective assessments also (eg "I think they would be fine in supportive community living, but would not trust them to navigate the homeless shelter system.")
-Medical care needs - wound cares, IV antibiotics, tracheostomy cares - greatly affected by presence of others in the home who may be able to assist with these needs. May also call into question ability to self-administer conventionally outpatient treatments (eg insulin injections). Depending on geography, may also be affected by travel distance (eg requires chemotherapy 3x/week but lives 3 hours away).
-Psychiatric needs - Generally pertaining to severity of mental illness and chronic symptoms. However may also be affected by geographical concerns (eg no access to index course of ECT as outpatient, proximity to clinics providing LAI administration).
-Need for intensive outpatient or inpatient treatment for substance use disorder and ability to access these services.
-Risk and ability of patient to elope from a care facility. Proximity of care facility to patient family members.
[Consider the comprehensivist notion connection to PCP AND Psych follow up or integrated primary care
Ask our SWers for their input on this section
Safety/readiness for discharge vs. "radical acceptance" of patients with chronic mental illness/housing insecurity]
It is highly unusual for a patient to be transferred from the MPU to a general med/surg unit. Generally this would only occur when the patient's psychiatric problems have become stable, but they require prolonged medical hospitalization. Some situations that come to mind are resolution of delirium but need for continued hospitalization for a course of chemo- or radiotherapy and resolution of acute suicidality but need for a surgery for which the surgical team wishes to take charge of postoperative care. In contrast, it is common for a patient's medical problems to stabilize but the acute psychiatric problem remains, in which case the patient is placed in queue for transfer to a general psychiatry unit. This does represent a discontinuity which to some extent goes against the spirit of MPUs, but given limited MPU capacities, this is likely the most efficient use of resources.
Obviously, if a patient deteriorates, ICU transfer becomes necessary. Our ICU colleagues often wish we could "hold" the bed for the patient to return to the MPU after improvement; the high demand for MPU beds usually makes this impossible, except in cases where the ICU stay is expected to be of a specified short duration (eg only for sedation for endoscopic retrieval of an ingested foreign object).
[Link to UR APP orientation binder, discharge note template/check-list]
Breaking down stigma of other providers and also providing the care that some patients have difficulty accessing.
. . . Like a stream carving a canyon . . .
Emphasize integrated care. Most important to advertise and educate psych consult, triage officers re: admission criteria, purposes and goals of unit.
Patients with good insight into their psychiatric conditions are generally readily agreeable to such transfers. For patients who are delirious or otherwise with poor insight (generally those with delusions), emphasize calming environment and holistic approach.
Patient orientation packet from University Hospitals (Case Western)