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Eliminate curtains from all patient accessible areas

April 10, 2014
by James M. Hunt, AlA
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Photos of possible solutions

Curtains may be the most widely used window treatment in so-called "typical residential environments." They can visually soften a room but they also present some very serious potential hazards. Many facilities feel that their inherent risks are too great to be acceptable, especially in areas where patients will be alone for long periods of time, such as the patient bedrooms and bathrooms.

Current thinking among some leaders in the field of behavioral healthcare design is now that curtains of all types should be eliminated from the patient environment. This includes curtains at windows, showers and privacy curtains in multi-patient rooms.

According to reports by The Joint Commission, 75% of inpatient suicides are by "hanging" and 86% of those take place in patient bedrooms or bathrooms1. However, the use of the term “hanging" is somewhat misleading. A loose definition is death by tying something around the neck. Often, these really are not even strangulations. Frequently, the cause of death is anoxia, which is lack of blood flow to the brain caused by tying something around the neck tightly enough to cut off blood flow to the brain2. If this is done, either death or irreparable brain damage will occur 4.5 to 5 minutes later. All that is necessary is for the patient to leave their body in a position that tension will be maintained on the ligature after the loss of consciousness. Therefore, the pounds of force that must be supported by the ligature can be much less than the person's total body weight.

The issues

Break-away attachments for curtains come in a variety of types including hook-and-loop (commonly referred to by the trade name Velcro), metal snaps or other plastic devices designed to disconnect when weight is exerted on them. Some of these are advertised by their manufacturers as being safe for use in psychiatric hospitals, but there have been a number of incidents involving these devices that suggest that facilities exercise extreme caution when using these items.

The main issue with these is that the load bearing capacity of all of the hangers on a particular curtain are additive. For example, consider a six-foot-long curtain that is supported by hangers that are designed to release at six pounds of weight. Because the manufacturer recommends a fastener every four inches of length of the curtain, 19 fasteners are needed to allow the curtain to hang. If this curtain is bunched up and the patient ties a knot in the fabric, or something is tied around the bunched up fabric, the combined holding weight of all the fasteners of 114 pounds will be achieved. This is more than enough holding force for a patient to use to commit suicide.

Some facilities have implemented a policy that no more than three break-away fasteners shall be used on any curtain. This would locate the fasteners eighteen inches apart on a three-foot-long curtain and thirty inches apart on a five-foot-long curtain. This results in a very unattractive looking installation.

One hospital reported that a patient successfully threaded a ligature through the track over the top of several of the carriers to obtain enough holding force to attempt suicide. There are also several other innovative ways patients have discovered to misuse these devices.

Even if the commonly recommended flush mounted track is provided and securely attached to a monolithic ceiling with no gaps, these frequently have a slot near one end of the track that is used to insert the carriers. This slot can be used by patients to insert other ligatures with the intent of harming themselves. This end portion of the track can easily be cut off before installation, but is frequently left in place to facilitate the removal of the curtain for cleaning and replacement. All ends of tracks that do not fit tightly to walls or other vertical surfaces also provide opportunities for patients to insert other items to use as ligatures.

If the curtain is removed by causing the break-away fasteners to release, the material can be used as a ligature in other ways such as tying a knot in the material and placing it over the top of a door and closing the door.

Possible solutions

Window curtains now have some good alternative solutions to control light and views. For example:




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