IMPROVING ADHERENCE TO THE WHO ANALGESIC LADDER: AUDIT AND SUBSEQUENT QUALITY IMPROVEMENT PROJECT IN A TERTIARY CARE HOSPITAL, PAKISTAN

Abstract

Background Pain is one of the most common symptoms encountered in hospitalized patients, yet adherence to evidence-based pain management guidelines remains suboptimal, particularly in low- and middle-income countries. The World Health Organization (WHO) analgesic ladder provides a structured, stepwise approach to rational analgesic prescribing; however, inappropriate early opioid use and excessive reliance on injectable analgesics are frequently observed in routine clinical practice. Preliminary observations at a tertiary care teaching hospital in Pakistan suggested poor compliance with the WHO analgesic ladder, especially widespread first-line use of intravenous tramadol. Objectives This clinical audit and subsequent quality improvement (QI) project aimed to assess baseline adherence to the WHO analgesic ladder, identify patterns of inappropriate analgesic prescribing, and evaluate the impact of targeted interventions on improving guideline-compliant pain management. Methods A prospective clinical audit using a Plan–Do–Study–Act (PDSA) cycle was conducted in a medical unit of a tertiary care hospital. A total of 200 adult inpatients receiving analgesics were included, with 100 patients assessed pre-intervention and 100 post-intervention. Prescribing practices were evaluated against WHO analgesic ladder standards, including initial analgesic step, opioid and tramadol use, route of administration, appropriateness according to documented pain severity, and pain reassessment. Following baseline analysis, a multifaceted intervention comprising clinician education, visual reminders, and reinforcement during ward rounds was implemented, followed by a re-audit using identical methodology. Results At baseline, adherence to the WHO analgesic ladder was poor, with only 22% of patients initiated on Step 1 analgesia, while 61% were started on Step 2 and 17% on Step 3. Overall compliance with WHO standards was 26%. Intravenous tramadol was used as first-line therapy in 58% of patients, and 49% received tramadol without prior use of paracetamol or NSAIDs. Oral analgesics were prescribed in only 31% of cases, and pain reassessment within 6 hours was documented in 21%. Following the intervention, initiation at Step 1 increased to 56%, while Step 2 and Step 3 initiation decreased to 34% and 10%, respectively. Overall compliance improved to 68%. Any tramadol use declined from 74% to 42%, and first-line intravenous tramadol use decreased from 58% to 21%. Oral route prescribing increased from 31% to 63%. Appropriateness of analgesic choice according to pain severity improved from 29% to 67%, and documented pain reassessment within 6 hours increased from 21% to 61%. Conclusion this audit demonstrated significant baseline non-adherence to the WHO analgesic ladder, characterized by premature opioid use, excessive reliance on injectable tramadol, and inadequate pain reassessment. Implementation of a targeted, low-cost quality improvement intervention resulted in substantial improvements in stepwise analgesic prescribing, reduced inappropriate opioid and injectable use, and enhanced pain monitoring. Regular audit and ongoing clinician education are effective strategies for improving rational pain management in resource-limited tertiary care settings.