Wind, Water, Wound, Walk Do the Data Deliver the Dictum?

Transcription

1 Wind, Water, Wound, Walk Do the Data Deliver the Dictum? Elizabeth M. Sonnenberg, MD, Caroline E. Reinke, MD MSHP, Edmund K. Bartlett, MD, Karole T. Collier, Giorgos C. Karakousis, MD, Daniel N. Holena, MD, Rachel R. Kelz, MD MSCE Perelman School of Medicine, University of Pennsylvania Department of Surgery, University of Pennsylvania Center for Surgery and Health Economics, University of Pennsylvania

2 Nothing To Disclose

3 Background Dictum wind, water, wound, walk has been used to teach the pattern of the timing of post-operative occurrences POD 1-3: wind or pneumonia (PNA) POD 3-5: water or urinary tract infection (UTI) POD 4-7: walking or pulmonary embolism (PE) or deep vein thrombosis (DVT) POD 5-1: wound or surgical site infection (SSI) PN A UTI DVT/PE SSI Post-Operative Day

4 Background Recent changes in the delivery of surgical care Increased ambulatory procedures Decreased length of stay following inpatient surgical procedures Increase in minimally invasive procedures Technological advances in diagnosis of post-operative occurrences

5 Specific Aims Objective 1: To evaluate the teaching dictum by determining the post-operative day of diagnosis of the different types of post-operative occurrences

6 Specific Aims Objective 1: To evaluate the teaching dictum by determining the post-operative day of diagnosis of the different types of post-operative occurrences Objective 2: To examine whether the time of diagnosis for each occurrence differed for the subset diagnosed before and after discharge

7 Methods Data Source: ACS NSQIP PUF 211 Inclusion Criteria: 18 years, underwent a general surgical procedure, and had a post-operative occurrence of interest Exclusion Criteria: active infection present at the time of surgery or missing data on day of diagnosis Post-operative occurrence of interest: Pneumonia Urinary tract infection Any surgical site infection Venous thromboembolic event

8 Methods Primary Outcome Variable: day of diagnosis of the first post-operative occurrence of interest Secondary Outcome Variable: discharge status at time of diagnosis Descriptive statistics, histograms, Kruskal-Wallis test, and Wilcoxon rank-sum test 11,137 patients studied

9 Overall Cohort Post-Operative Occurrence Wind Water Wound Walk Pneumonia Urinary Tract Surgical Site Venous Thromboembolism N (%) 1521 (.8) 248 (1.1) 6673 (3.6) 115 (.6) Median Day [IQR] 5 [2, 9] 8 [4, 16] 11 [7, 17] 9 [4, 15] Dictum Order differed significantly across the types of post-operative occurrences examined (p<.1)

10 Overall Cohort Overall Cohort PNA Post-Operative Occurrence Pneumonia Urinary Tract Surgical Site Venous Thromboembolism Median Day [IQR] 5 [2, 9] 8 [4, 16] 11 [7, 17] 9 [4, 15] UTI SSI VTE

11 Overall Cohort IQR for all postoperative occurrences were much wider than the narrow day range in the dictum Overall Cohort PNA UTI IQR depicted in gray SSI VTE

12 Stratified by Discharge Status Diagnosed Before Discharge Number (%) Diagnosed After Discharge p-value Pneumonia 123 (81.7) 275 (18.3) n/a Urinary Tract 962 (47.1) 182 (52.9) n/a Surgical Site 2276 (34.2) 4385 (65.8) n/a Venous Thromboembolism 584 (53.) 517 (47.) n/a

13 Stratified by Discharge Status Diagnosed Before Discharge Number (%) Diagnosed After Discharge p-value Pneumonia 123 (81.7) 275 (18.3) n/a Urinary Tract 962 (47.1) 182 (52.9) n/a Surgical Site 2276 (34.2) 4385 (65.8) n/a Venous Thromboembolism 584 (53.) 517 (47.) n/a

14 Stratified by Discharge Status Diagnosed Before Discharge Number (%) Diagnosed After Discharge p-value Pneumonia 123 (81.7) 275 (18.3) n/a Urinary Tract 962 (47.1) 182 (52.9) n/a Surgical Site 2276 (34.2) 4385 (65.8) n/a Venous Thromboembolism 584 (53.) 517 (47.) n/a

15 Stratified by Discharge Status Diagnosed Before Discharge Number (%) Diagnosed After Discharge p-value Pneumonia 123 (81.7) 275 (18.3) n/a Urinary Tract 962 (47.1) 182 (52.9) n/a Surgical Site 2276 (34.2) 4385 (65.8) n/a Venous Thromboembolism 584 (53.) 517 (47.) n/a Median Day of Diagnosis [IQR] Pneumonia 4 [2, 7] 1 [5, 18] <.1 Urinary Tract 5 [3, 8] 14 [8, 21] <.1 Surgical Site 7 [5, 9] 14 [1, 2] <.1 Venous Thromboembolism 5 [3, 9] 14 [9, 2] <.1

16 PNA Diagnosed Before Discharge Diagnosed A er Discharge Stratified by Discharge Status fg Urinary 3 3 UTI SSI VTE Su Venous Su Venous Order differed significantly across the types of post-operative occurrences examined for both before and after discharge (p<.1)

17 Conclusions The dictum should be taught as, "wind, water, walk, wound" to reflect the timing and progression of the diagnosis of PNA, UTI, VTE and SSI in the overall cohort and before discharge cohort. The dictum does not reflect the timing of diagnosis in the after discharge cohort Surgical educators must incorporate education about diagnosis after discharge

18 Thank You! Mentor Rachel Kelz, MD MSCE Research Team Dan Holena, MD Giorgos Karakousis, MD Caroline Reinke, MD MSHP Ned Bartlett, MD Becky Hoffman, MD Heather Wachtel, MD Karole Collier Questions?

19 Limitations

20 Study Population 186,251 patients were initially eligible 11,137 patients remained

21 Overall Cohort Overall Cohort PNA Post-Operative Occurrence Wind Water Wound Walk Pneumonia Urinary Tract Surgical Site Venous Thromboembolism N (%) 1521 (.8) 248 (1.1) 6673 (3.6) 115 (.6) Median [IQR] 5 [2, 9] 8 [4, 16] 11 [7, 17] 9 [4, 15] Dictum UTI SSI Order differed significantly across the types of post-operative occurrences examined (p<.1) VTE

22 Discussion Day of diagnosis after discharge occurred later than the day of diagnosis before discharge Difference in day of onset? Delay in detection?

23 Discussion Day of diagnosis after discharge occurred later than the day of diagnosis before discharge Difference in day of onset? Delay in detection? by Post-operative occurrences occur later than recognized the original teaching dictum

24 Conclusions The dictum wind, water, wound, walk was supported by the progression of post-operative occurrences in the overall cohort and subset diagnosed before discharge

25 Overall Cohort PNA Post-Operative Occurrence Wind Pneumonia Water Wound Walk Urinary Tract Surgical Site Venous Thromboembolis m Number (%) 1521 (.8) 248 (1.1) 6673 (3.6) 115 (.6) Median [IQR] 5 [2, 9] 8 [4, 16] 11 [7, 17] 9 [4, 15] UTI SSI Order differed significantly across the types of post-operative occurrences examined (p<.1) VTE

26 Study Population 186,251 patients were initially eligible EXCLUD ED: 163 patients had an infection at surgery 184,621 patients 12,726 post-operative occurrences 291 lacked a day of diagnosis 188 were not the first postoperative occurrence 11,137 patients remained

27 Study Population 186,251 patients were initially eligible defined as: Enrolled in NSQIP PUF 211 & Age ,621 patients were remained eligible 12,726 total post-operative occurrences of interest were identified 1,735 PNAs, 2,369 UTIs, 7,37 SSIs, 1,315 VTEs 163 patients had an infection at surgery 241 had a superficial SSI 12 had a deep SSI 636 had an organ space SSI 24 had a PNA 393 had a UTI 291 post-operative occurrences lacking PODD: 18 PNAs; 131 UTIs; 122 SSIs; post-operative occurrences were not the first post-operative occurrence 11,137 patients remained

28 PNA UTI SSI VTE Diagnosed Before Discharge fg Su Venous Diagnosed A er Discharge Urinary Su Venous Stratified by Discharge Status Order differed significantly across the types of post-operative occurrences examined for both before and after discharge