Improving Adherence to the WHO Analgesic Ladder for Postoperative Pain Management: A Closed-loop Audit from a Tertiary Hospital in India

Background: Postoperative pain management remains inconsistent in high-volume surgical units, particularly in low-and middle-income countries.Adherence to the WHO analgesic ladder and recommended pain assessment practices are often suboptimal.Methods: A closed-loop clinical audit was conducted in a tertiary care general surgery department.Adult patients undergoing elective procedures were assessed for compliance with predefined standards based on WHO analgesic ladder principles and NICE guidelines.Parameters included pain score documentation, stepwise analgesic prescribing, multimodal analgesia use, appropriate opioid initiation, and timely pain reassessment.Following the first audit cycle, targeted interventions-structured documentation tools, staff education, and visual reminderswere implemented, and a second cycle was performed.Results: A total of 59 patients were included in the first cycle and 60 in the second.Baseline adherence to pain management standards was low.Postintervention, improvements were observed across most parameters, particularly in pain reassessment within 60 minutes (15.2 to 48.3%).Overall compliance increased from 15.2 to 26.6%.Conclusion: A closed-loop audit combined with simple, low-cost interventions significantly improved adherence to evidence-based postoperative pain management practices.Such strategies are feasible and effective in resource-constrained surgical settings.