When I became the clinical director of the four-OR, two-procedure-room Corinth Surgery Center, my new office was located just around the corner from the recovery room. I was struck by the crying and struggling I heard as our pediatric patients emerged from anesthesia in our PACU ' something I hadn't witnessed at my previous eight-OR, eight-room GI lab facility.

I found myself assigning additional staff to the PACU when pediatric patients were scheduled. To add to the problem, we identified a pattern of patient and staff injuries ' scratches, bruises, bites ' due to combative anesthetic emergence of pediatric patients. We had three incidents during 2003, four during 2004 and another four in the first four months of 2005. Installing side rail pads proved to be of little help in curbing the combative behavior. It wasn't long before we started looking for a real solution. But it would be no small task.

A little detective work
First, we attempted to discern the causes of pediatric patients' combativeness: separation anxiety, anesthetic emergence delirium, fear or pain. We reasoned that it could be caused by any combination of these factors. We investigated separation anxiety as the leading cause of combative emergence, but allowing parents into the PACU as soon as possible post-op only added to our frustrations. That led us, as PACU nurses and patient advocates, to believe our best option was to explore pain as the cause.

So, with pain relief as our top priority, we began to concentrate our efforts on administration of drugs. Our facility's standing orders for PACU called for the administration of morphine as the drug of choice, and we tried to be more vigilant about heading off pain. While it was in line with conventional knowledge about pain treatment, our nurse anesthetists' practice of administering morphine and fentanyl immediately before transport to the PACU left nurses unable to assess patients' responses for 15 to 20 minutes due to the drugs' long peak times.

Assessment is crucial because there is a marked individual variation in opioid dose requirements, and to treat acute pain, you need to be able to administer the opioid dose that treats the pain but doesn't result in excessive somnolence or respiratory depression. However, suggestions made to the nurse anesthetists were met with disdain, objection and, in some cases, open hostility. They saw administration as trying to tell them how to practice. The PACU nurses, on the other hand, accused the nurse anesthetists of "dosing and dumping" the patients in the recovery room for them to deal with.

We were beginning to run out of ideas when it hit us: We should compare the variables in practice between Corinth Surgery Center and my old facility. What we discovered was simple but surprisingly on target and, best of all, something we could control. As it turns out, my old facility used meperidine (Demerol) instead of morphine for post-op pain relief for pediatric patients in the PACU.

Comparing the choices
Our team collected and assessed data to determine an effective alternative drug therapy based on rapid onset and peak effects as well as length of duration based on documented outcomes. We began to examine and compare the properties of meperidine with those of morphine and fentanyl and found that meperidine has an amazingly short peak time and a long duration of action ' matching fentanyl's peak time and morphine's duration (see "How the Opioids Stack Up").

This realization kicked off our performance improvement project in which we started using meperidine. I have to say, the immediate onset and rapid peak of meperidine was unbelievable in comparison to morphine. When pediatric patients were dosed with morphine, the nurses in the PACU had to continue to wrestle ' or, as we like to call it, protectively restrain ' them for 15 to 20 minutes, waiting for the morphine to peak. But with meperidine, the children rested comfortably, and the nurses were able to do their jobs. As a result, children would progress through the excitement phase of anesthetic emergence (with associated delirium) while sedated, then were oriented and ready for their parents at bedside.

Now, we'd found a way to nearly eliminate combative behavior, promote tranquil pediatric emergence, reduce patient and staff injuries, and decrease PACU staffing needs. Despite the clear benefits, that wasn't the end of it.

Instituting the fix
Both our staff and our anesthesia department resisted the change. While PACU nursing staff were ready to try anything that might help (after being the recipients of scratching, hitting and even biting), they were hesitant because they weren't familiar with the dosing differences. Anesthesia perceived our study as interference into their scope of practice. Our medical director, contract pharmacist, administrator, two PACU nurses and myself collaborated to formulate a plan of action and new standing orders that everyone was able to agree on.

• Nurse training. After thoroughly training the PACU nurses in nursing considerations, dosages, meperidine's interactions with other medications, potential adverse drug reactions and indications for administration of medications, the PACU nurses were able to demonstrate competence in their understanding and the use of meperidine as compared to morphine.
• Anesthesia reassurance. We had to assure our nurse anesthetists that we weren't trying to tell them how to practice. This is where our medical director, who is also an anesthesiologist, was a huge help, convincing them that what the task force was trying to do would be best for everyone.
• Standing orders. These dictated the administration of the meperidine and provided for data collection and monitoring by the PACU nurses (see "Pediatric Recovery Room Routine Standing Orders" on page 37).

The benefits were numerous, as I've already recounted. But the best part: I freed up those extra nurses I'd previously had to assign to the PACU for pediatric cases. The staffing cost savings was $18,304 last year and is projected at $36,808 this year. Not to mention the dramatic decrease in the noise level outside my office ' which I'm sure makes patients and staff alike more relaxed.

Not mutually exclusive
When a child suffers, natural empathy causes us, as adults, to feel pain. It's difficult for nurses to use good judgment to treat a child if that adult nurse is overwhelmed by sympathetic feelings toward the suffering child. By setting up protocols that help us deal with situations where children are in pain more calmly ' but no less empathetically ' we've been able to care for our pediatric patients more safely and efficiently. Since April 2005, we've had just two incidents ' one in the remainder of last year, and one so far this year.