Complexity Intervention Units Past And Present

James Amos

Dec 31

Here's another blast from the past about Complexity Intervention Units (CIUs) or what used to be called Medical-Psychiatry Units. I co-staffed one for 17 years at Iowa Health Care, the organization formerly known as Prince. No wait, that used to be called the University of Iowa Hospitals & Clinics. They're rebranding.

I was looking up CIU on the web. It's a common search term now, so Roger Kathol, the guy who built the CIU at Iowa Health Care, was right.

On the other hand, I was also puzzled when the results showed that a hospital in Wisconsin has what's called a brand new CIU-only it's not a psychiatric unit.

I thought a CIU was, by definition, a combined specialty unit, with facilities for acute care of both psychiatric and medical problems. But Froedtert Medical Center in Milwaukee has a new CIU and yet says: "The department is licensed as a Medical Unit – not a Psychiatric Unit."

In fact, Medical College of Wisconsin says essentially the same thing about the CIU: "Please note that the CIU is not an inpatient psychiatric unit, but rather a facility dedicated to integrated care."

OK, so I probably missed the memo about what a CIU is nowadays. It's tough to find out how many CIUs are in operation in the U.S., maybe partly depending on how you define it and who you ask. Anyway, this is what I wrote about them 12 years ago:

The Complexity Intervention Unit for Managing Delirious Patients

Is there such a thing as a specialized unit in the general hospital where patients with delirium could be treated, where both their medical and behavioral issues could be managed by nurses and doctors specifically trained for that purpose? It turns out there is. Although they are usually called medical-psychiatry units, an internationally recognized expert about designing and staffing these specialized wards, Dr. Roger Kathol, M.D., F.A.P.M., would prefer to call them "Complexity Intervention Units" (CIUs). It's a mouthful, but it's a better description of the interaction between physical and psychiatric illness, along with social and health care system challenges typically managed in these units.

We've had one at Iowa since Dr. Kathol started it in 1986. It was one of the first such units built and now that it has been redesigned, updated, and beds with cardiac monitors added, it's arguably the only unit of its kind in the country. The CIU allows us to provide both intensive medical and psychiatric interventions that would be all but impossible to deliver on general medical floors with psychiatric consultation. The essential features of the CIU include:

Both medical and psychiatric safety features in the physical structure.
Consolidated general-medical and psychiatric policies and procedures.
Location in the general hospital under medical bed licensure and with psychiatric bed attributes.
Moderate-to-high medical and psychiatric acuity capability.
Physicians from combined residencies general medicine and psychiatry co-attending model with consistent communication and coordination of medical and psychiatric care.
Nurses and other staff cross-trained in medical and psychiatric assessments and interventions.

The unit is used to optimize management of a variety of patients with both medical and psychiatric diagnoses. The focus is on providing care for the 2%-4% of patients admitted to general hospitals who are too complicated to manage on either psychiatric or medical units. And it's an excellent teaching resource for helping new doctors learn about the inevitable interaction between medical and psychiatric disorders in an environment that fosters both/and thinking. Trainees learn that delirium mimics nearly every other psychiatric disorder and how to distinguish delirium from primary psychiatric illness.

I co-staff the unit with a colleague from internal medicine when I'm not staffing the general hospital consultation service. That helps me blend the perspectives of each role. Often, acting in the role of psychiatric consultant, I can assist the generalist in managing patients with less complicated delirium without transferring them to the CIU. And for those whose behavioral challenges would be overwhelming for nurses and physicians on open medical units, it's helpful to have the CIU option available.

While the CIU is a great resource for managing delirious patients, they are expensive to build and generally have a limited number of beds. So it's still important to continue work on developing practical delirium early detection and prevention programs in every hospital.