Eliminate curtains from all patient accessible areas

While windows and natural light are necessary in treatment facilities, curtains present serious potential danger

Curtains maybe 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.

Background

According to reports by The Joint Commission, 75 percent of inpatient suicides are by "hanging" and 86 percent of those take place in patient bedrooms or bathrooms'. 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 hookand-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 breakaway 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:

* Mini-blinds installed behind security glazing are one commonly used solution. These installations can be accomplished in several different ways. The simplest is to install a conventional mini-blind in an opening and then provide security glazing on the room side of the blind to resist the patient's ability to access the slats and cords of the blind. This can result in blinds that are very difficult to adjust and need to be cleaned periodically.

* Several manufacturers now offer factory assembles that are sealed units with miniblinds inside the units and ligature resistant operating devices to adjust the tilt of the blinds. These can be designed so patients can adjust the tilt or so that only staff can make the adjustments. A variety of glazing materials can be ordered including polycarbonate (commonly referred to by the trade name Lexan) or one of the new "hurricane" glass assemblies. These assemblies are also applicable for interior windows and can be used in openings through both walls and doors.

* Roller blinds are now available which the manufacturer claims are safe for use in behavioral healthcare patient areas. These have the roller secured in a tamper-resistant enclosure and include features to minimize tampering by patients and that limit the hazardous nature of pieces if the operating assembly or shade are damaged. It is suggested that a sample be obtained by the facility that is considering this option. The Risk Management and Safety Programs should evaluate the appropriateness of this product (and any other product) being considered.

Shower curtains mounted on breakaway fasteners have the same potential hazards discussed above. When designing new construction projects, it is preferred to eliminate the need for a shower curtain altogether.

Some ways to do this include:

* To design the shower stall with a short wall that will help contain the water from the shower or by mounting the shower head on this wall so that it sprays away from the opening through which the patient enters the stall. Installation of a trench drain across the entrance opening can also help keep water from getting out of the stall and let water that does get out of the stall drain back. The floor will need to slope to the trench drain for this to be effective (Figure 2).

* Another solution is to place the drain pan under the floor finish of the entire bathroom. This means that the entire bathroom is essentially designed as the shower. This is sometimes referred to as a European style bathroom. Of course, slip resistant flooring and other accommodations need to be included in the design of these rooms.

* In some existing situations, retaining shower curtains may be the only practical solution. When this is the case, it is suggested that the absolute minimum number of break-away fasteners be provided and the curtains be made of "breathable" fabric, which creates less risk of suffocation. In these instances, staff should be trained that this potentially hazardous condition is present and to be alert for possible misuse of the curtain.

Cubicle curtains are also discouraged because of the ligature issues discussed above. These are typically not provided in ambulatory behavioral health facilities. If a facility has a patient population that has co-existing medical and psychiatric issues, they may find it necessary to provide these in two-patient rooms.

If the facility's Risk Management and Safety Programs support the need for cubicle curtains, the tracks should be mounted flush with the ceiling and the curtains should not have chain or cord extensions. The carriers should be non-metallic break away items and the staff should be trained regarding the potential hazards these represent. Some facilities elect to use portable dividers to achieve visual privacy when needed, but these dividers can be broken and used as weapons.

Conclusion

Curtains present potential hazards for behavioral healthcare patients and staff. Facilities and their designers are encouraged to find ways to remove them from the patient environment whenever possible. All "Authorities Having Jurisdiction" should be consulted before making alterations to the physical environment to make sure that they are in compliance with requirements at that particular location.

More information on products available to assist with this effort may be found in the "Design Guide for the Built Environment of Behavioral Health Facilities" that is published by the National Association of Psychiatric Health Systems (NAPHS) and may be downloaded free of charge at www.naphs.org. *

References:

1. Thcjoint Commission. (2007). Suicide Prevention: Toolkit for Implementing National Safety Goal 15A: Joint Commission Resources.

2. The Joint Commission on Accreitation of Healthcare Organizations. (2000). Preventing Patient Suicide. Oakbrook Terrace, IL: The Joint Commission.

BY JAMBS M. HUNT, ALA

James M. Hunt, AIA, is a practicing architect and facility management professional. He was director of facilities management for the Menninger Clinic for 20 years. He is the co-author of the "Design Guide for the Built Environment of Behavioral Health Facilities'* (www.naphs.org). He now consults with psychiatric hospitals on improving patient and staff safety and may be contacted at jimebhfcllc.com.