Evaluating a perioperative pain management bundle in South Africa: a registry-based quality improvement study

Abstract

Background The Lancet Commission on Global Surgery urges expanding surgical services to promote equity. Yet postoperative pain, a core feature of surgical care, remains inadequately managed in many settings, particularly in low- and middle-income countries (LMICs). Consequently, if pain management programs do not develop alongside surgical expansion, the result may be avoidable suffering, increased morbidity, and mortality. This study evaluated the implementation of a four-element perioperative pain management bundle and examined its association with patient-reported outcomes. Methods An observational pre-post study in ten South African hospitals using the PAIN OUT methodology, a standardised approach to capturing postoperative patient-reported outcomes. The ‘Perioperative Pain Management' bundle had four evidence-based interventions designed for flexible local adaption. We assessed bundle implementation and explored associations between number of elements received and a multidimensional composite pain score (CPS). Findings Data from 3522 patients across five surgical disciplines showed significant bundle implementation. Patients receiving all elements had significantly better CPS than those receiving none/one/two/three elements (small-to-medium effect size). Regression analysis (n = 1880) identified patient education as the most effective element for improving CPS. Interpretation The bundle approach may help close a critical gap in Global Surgery by demonstrating that context-adapted perioperative pain management bundles can be feasibly implemented in diverse South African hospitals and improve patient-reported outcomes. Diverse clinical disciplines successfully implemented the bundle, enhancing perioperative care. By aligning with international guidelines and emphasising patient engagement, it supports a shift toward holistic, patient-centred surgical care in LMICs. As surgical access expands, pain must become visible, measurable, and manageable through scalable, interdisciplinary strategies. Funding PAIN OUT was established with funding from the European Community's FP7 Program (Grant No. 223590). The South African study was supported by an unrestricted educational grant from Pfizer Global Medical Grants (Grant 44100819), covering PAIN OUT subscription costs for 2 years and partial hospital remuneration for data collection. Pfizer had no role in the protocol, analysis, or manuscript preparation.