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 re- traumatisation 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 SaO 2 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 %26.25% May503570%918% June442250%818.1% July %00% August %00% September %00% October %10.75% November %00% December1900%0 January3525.7%00% February5235.7%11.9% March2428.3%00%

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...