Background Hospice in-patients taking opioids are at risk of life-threatening opioid induced respiratory depression (OIRD). Time-critical naloxone administration can be life-saving. Simulation is used in medical training (Herron, Harbit & Dunbar, 2018. BMJ Evid Based Med. Jul 27; Saunsbury & Allison, 2015. BMJ Open Qual. 4,1), but in palliative care typically focuses on communication (Evans & Taubert, 2019. BMJ Support Palliat Care. 9:117) or terminal symptoms (Sooby, Tarmal & Townsley, 2020. BMJ Open Qual. 9,4; Kozhevnikov, Morrison & Ellman, 2018. Adv Med Educ Pract. 9:915).

Aims Following a difficult OIRD case, we used simulation to improve in-hospice OIRD management. Our SMART objective was ‘to reduce time to administer naloxone from 11 to 5 minutes within 4 months’ whilst ensuring practice was consistent and following guidance.

Methods Quality-improvement methodology was used, and interventions tested in ‘plan-do-study-act’ cycles. Four pilot studies refined the simulation and produced a baseline time: 11 minutes.

Cycle 1: Three repeated simulations by one doctor-nurse pair.

Cycle 2: New pair completed three simulations, grab-box containing required equipment introduced and further 3 simulations undertaken.

Cycle 3: Ongoing with amendment of hospice opioid toxicity guidelines to ensure consistent prescriptions and medication administration.

Results Cycle 1: repeated simulation consistently reduced the time to prepare equipment (8:19 to 3:36) and time to administer naloxone (14:30 to 8:25).

Cycle 2: reproduced similar results from Cycle 1 confirming repetition was effective; time to prepare equipment (4:58 to 2:05) and time to administer naloxone (12:00 to 6:31). Grab box introduction demonstrated further reduction in time to prepare equipment to 00:55 and time to administer naloxone to 5:15.

Grab box contents were amended according to simulation observations to lead to finalised format.

Both cycles identified inconsistent prescriptions, medication administration and use of guidelines prompting Cycle 3.

Conclusion This novel use of simulation reduced total time to naloxone administration improving hospice management of OIRD. Simulation gave us the ability to problem solve in real time to improve our interventions (the grab bag and guidelines). Simulation training could be implemented within the hospice to improve management of other medical emergencies or as mandatory training.