title: Wind, water, wound, walk--do the data deliver the dictum?
abstract: OBJECTIVE
  To evaluate the teaching dictum "wind, water, wound, walk" in the modern surgical environment.
  
  
  METHODS
  A retrospective cohort study.
  
  
  METHODS
  Hospitals enrolled in the American College of Surgeons National Surgical Quality Improvement Program.
  
  
  METHODS
  We identified 11,137 patients enrolled in American College of Surgeons National Surgical Quality Improvement Program Participant Use File (2011) who were older than 18 years; underwent a general surgical procedure; and developed a postoperative pneumonia (PNA, "wind"), urinary tract infection (UTI, "water"), surgical site infection (SSI, "wound"), or venous thromboembolic event (VTE, "walk") for inclusion in the study. Patients were excluded if they had an infection present at the time of surgery or were missing information on the time of diagnosis.
  
  
  RESULTS
  The median day of diagnosis differed significantly according to occurrence type (median day of PNA = 5, UTI = 8, SSI = 11, and VTE = 9, p < 0.001). The sequence of occurrences diagnosed before discharge (median day of PNA = 4, UTI = 5, SSI = 7, and VTE = 5) differed from that of occurrences diagnosed following discharge (median day of PNA = 10, UTI = 14, SSI = 14, and VTE = 14). Within the predischarge and postdischarge subsets, the median day of diagnosis remained significantly different according to occurrence type (all p's < 0.001).
  
  
  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. The dictum did not reflect the timing or sequence of the occurrences in the cohort diagnosed after discharge. Educators must teach trainees to apply the dictum in the appropriate patient setting. As surgical care changes, we must continue to reassess our educational pearls to ensure that they reflect the modern reality.
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address: Rachel.kelz@uphs.upenn.edu.
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Sonnenberg
authors.affiliation: Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Caroline E
authors.initials: CE
authors.lastname: Reinke
authors.affiliation: Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Edmund K
authors.initials: EK
authors.lastname: Bartlett
authors.affiliation: Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Karole T
authors.initials: KT
authors.lastname: Collier
authors.affiliation: Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Giorgos C
authors.initials: GC
authors.lastname: Karakousis
authors.affiliation: Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Daniel N
authors.initials: DN
authors.lastname: Holena
authors.affiliation: Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Rachel R
authors.initials: RR
authors.lastname: Kelz
mesh_terms: D039702:Current Procedural Terminology; D013502:General Surgery / Q000193:education*; D006801:Humans; D008568:Memory; D011014:Pneumonia / Q000453:epidemiology*; D011183:Postoperative Complications / Q000175:diagnosis / Q000453:epidemiology*; D058996:Quality Improvement; D013530:Surgical Wound Infection / Q000175:diagnosis / Q000453:epidemiology; D013997:Time Factors; D014552:Urinary Tract Infections / Q000175:diagnosis / Q000453:epidemiology*; D054556:Venous Thromboembolism / Q000175:diagnosis / Q000453:epidemiology
keywords: Medical Knowledge; Patient Care; Practice-Based Learning and Improvement; educational dictum; postoperative complications; postoperative fever; postoperative occurrences