SILAS – A New Approach to
Inpatient Ligature Management
Louise McKenna Ward Manager
Dr David Kingsley Consultant Psychiatrist
Woodlands Unit
The Priory Hospital Cheadle Royal
Context
• Unsuspended ligatures are commonly seen in adolescent
inpatient units, particularly in young people with emerging PD
• Risks often escalate in acute units and tying ligatures may be a
new behaviour seen in this context
• Such actions may or may not be with suicidal intent and may
serve a variety of psychological needs and functions
• Often ligatures lead to high levels of arousal in patients and
staff – who may respond reactively by engaging in a physical
intervention to remove the ligature immediately
• This approach leads to increased restraints, assaults on staff,
staff injuries, rapid tranquilisation and an experience of retraumatisation for a young person who may have been abused
Background to SILAS
• On analysing our interventions we were giving a message of
“this is inappropriate and we will stop you doing this”
• What we were not doing was giving the Young Person
opportunity to communicate their distress or learn how to
regain control and develop new/ safer coping strategies
• High levels of ligatures on the unit were leading to high levels
of resistance in restraint and consequent staff injuries
• We aimed to balance the need for support, maintaining safety
(for both the young person and staff),encourage individual
responsibility and encourage more adaptive coping stategies
SILAS Protocol
• SILAS is a scoring tool that can be used by both qualified and
unqualifed nursing staff and considers these 3 areas:
Circulation
• monitors the physical health of the young person
Engagement and Co-operation
• ensures physical safety of the staff team and encourages
responsibility
Time Limits
• gives support whilst encouraging the Young Person to regain
control for themselves
Use of SILAS Scoring
• Nursing staff calculate a score comprising physical wellbeing of the
young person, their compliance and consciousness and the time
since the ligature event.
• Whilst the score remains below 7, staff will sit and reflect with the
young person and encourage them to remove the ligature or comply
with staff intervention.
• If, at any time, circulation deteriorates (as evidenced by continual
SaO2 monitoring) or conscious level reduces, staff will actively
intervene.
• No ligature would be left in situ for longer than 15 minutes.
Before the tool could be implemented:
•
•
•
•
•
Discussion and validation by the MDT
All staff completed observation and engagement competencies
All staff trained in Basic Life Support
All staff trained in the safe removal of ligatures
All staff trained in the S.I.L.A.S. scoring and interventions and
competencies assessed
• All staff have ongoing supervision and annual review of their
competencies
• All YPs have an Individual Risk Management Plan in place which
includes their Individual Intervention Score and their Individually
agreed “SAFE SIGNAL”
• The staff team have protected time for de-briefing and reflection
around incidents
SILAS Procedure
•
All incidents of Unsuspended Ligature require a minimum of 2 staff
•
The role of Nurse A is:
–
•
To engage with the Young Person and make an initial assessment / score, paying particular
attention to Level of Engagement and Co-operation. Throughout the incident Nurse A
will be continually communicating with the Young Person and encouraging them to remove
the ligature themselves or to seek confirmation from the Young Person that they are willing
for the nurse to remove this for them.
The role of Nurse B is:
–
–
–
–
–
To monitor Circulation through the use of a pulse oximeter.
To monitor the Time Scale.
To monitor the Level of Engagement and Co-operation by observing the
communication between the Young Person and Nurse A
To keep Nurse A informed of changes in the S.I.L.A.S. Score as they occur.
To organised support from extra staff if required (see flow chart)
Benefits of SILAS
Month
Total No.
Unsuspended
Ligatures (UL)
Total No.
Requiring MVA
Restraint
% UL
Requiring
Restraint
No. Staff
Injuries due to
UL
% Staff
Injuries in MVA
re UL
April
32
23
71.8%
2
6.25%
May
50
35
70%
9
18%
June
44
22
50%
8
18.1%
July
39
8
20.5%
0
0%
August
106
12
11.3%
0
0%
September
43
11
25.5%
0
0%
October
133
15
11.2%
1
0.75%
November
35
6
17.1%
0
0%
December
19
0
0%
0
0%
January
35
2
5.7%
0
0%
February
52
3
5.7%
1
1.9%
March
24
2
8.3%
0
0%
Quotes from Young People:
•
“In my other placement they used to handle tying things round your neck on my
other placement, they used to rush in and cut it off, no communication and leave
you and go and have a debrief, but when they came in they would frighten the
living daylights out of you but here on Woodlands they come in and talk to you and
try to help you take it off and after they would talk to you and help you with what
you are struggling with” .
‘Queen of Chaos’
•
“When I was on ... if I ligatured the alarms would be pulled and a full team would
come in and restrain me to take it off. The sound of the alarm made me feel more
anxious. The full team all running in made me feel worse and when the team put
hands on me it made me feel worse and reminded me of bad things. But now on
Woodlands if I ligature they persuade me to take it off myself, staff sit with me and
give me reassurance, this makes me feel better and less anxious. Woodlands staff
would only restrain me as a last resort or if my life was at risk. I think I ligatured
more on ... because of the way it was dealt with, it gave me more attention where
as on Woodlands the way they deal with it made me feel safer and was less of a big
deal and more discreet from other patients”.
Saint SILAS
all the prison doors flew open, and everyone’s chains came loose...