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

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

Nothing To Disclose

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 1 5 1 Post-Operative Day

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

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

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

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

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

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 1-3 3-5 5-1 4-7 Order differed significantly across the types of post-operative occurrences examined (p<.1)

Overall Cohort 5 4 3 2 1 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] 5 4 3 2 1 5 4 3 2 1 5 1 15 2 25 3 UTI 5 1 15 2 25 3 SSI 5 1 15 2 25 3 5 4 3 2 VTE 1 5 1 15 2 25 3

Overall Cohort IQR for all postoperative occurrences were much wider than the narrow day range in the dictum 5 4 3 2 1 5 4 3 2 1 Overall Cohort PNA 5 1 15 2 25 3 UTI 5 1 15 2 25 3 IQR depicted in gray 5 4 3 2 1 SSI 5 1 15 2 25 3 5 4 3 2 1 VTE 5 1 15 2 25 3

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

PNA 3 25 2 15 1 5 Diagnosed Before Discharge 3 25 2 15 1 5 Diagnosed A er Discharge Stratified by Discharge Status 5 1 15 2 25 3 fg 5 1 15 2 25 3 Urinary 3 3 UTI 25 2 15 1 25 2 15 1 5 5 5 1 15 2 25 3 5 1 15 2 25 3 SSI VTE 3 25 2 15 1 5 3 25 2 15 1 Su 5 1 15 2 25 3 Venous 3 25 2 15 1 5 3 25 2 15 1 Su 5 1 15 2 25 3 Venous Order differed significantly across the types of post-operative occurrences examined for both before and after discharge (p<.1) 5 5 5 1 15 2 25 3 5 1 15 2 25 3

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

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?

Limitations

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

Overall Cohort 5 4 3 2 1 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 1-3 3-5 5-1 4-7 5 4 3 2 1 5 4 3 2 1 5 1 15 2 25 3 UTI 5 1 15 2 25 3 SSI 5 1 15 2 25 3 Order differed significantly across the types of post-operative occurrences examined (p<.1) 5 4 3 2 1 VTE 5 1 15 2 25 3

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

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

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

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

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

Study Population 186,251 patients were initially eligible defined as: Enrolled in NSQIP PUF 211 & Age 18 184,621 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; 2 188 post-operative occurrences were not the first post-operative occurrence 11,137 patients remained

PNA UTI SSI VTE Diagnosed Before Discharge 2 15 1 5 5 1 15 2 25 3 fg 14 12 1 8 6 4 2 5 1 15 2 25 3 Su 3 25 2 15 1 5 5 1 15 2 25 3 Venous 7 6 5 4 3 2 1 5 1 15 2 25 3 Diagnosed A er Discharge 2 15 1 5 5 1 15 2 25 3 Urinary 14 12 1 8 6 4 2 5 1 15 2 25 3 Su 3 25 2 15 1 5 5 1 15 2 25 3 Venous 7 6 5 4 3 2 1 5 1 15 2 25 3 Stratified by Discharge Status Order differed significantly across the types of post-operative occurrences examined for both before and after discharge