Target Audience (click to view)
This activity is designed to meet the needs of physicians.
Learning Objectives(click to view)
Upon completion of the educational activity, participants should be able to:
- Describe the Rule of W mnemonic that was developed to chronicle the most common causes of postoperative fever in the order in which they occur.
- Review the findings of a study that aimed to develop a simple, evidence-based mnemonic that can be applied to the teaching and diagnosis of postoperative complications.
Method of Participation(click to view)
Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation. A statement of credit will be available upon completion of an online evaluation/claimed credit form at www.akhcme.com/pwMar1. You must participate in the entire activity to receive credit. If you have questions about this CME/CE activity, please contact AKH Inc. at email@example.com.
Credit Available(click to view)
CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s. AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.
AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Commercial Support(click to view)
There is no commercial support for this activity.
Disclosures(click to view)
It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.
Disclosure of Unlabeled Use & Investigational Product(click to view)
This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Disclaimer(click to view)
This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.
Faculty & Credentials(click to view)
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
AKH planners and reviewers have no relevant financial relationships to disclose.
Complete the Post Test(click to view)
Historically, mnemonics have been used in medicine to facilitate learning and provide clinicians with tools to enhance their care of patients. These memory devices are often applied on hospital wards, in EDs, and in primary care settings long after surgical rotations end. While some mnemonics have been tried and tested, others go invalidated in clinical trials and may actually contribute to incomplete or misguided assessments of patients. This can be especially problematic when diagnosing postoperative complications. “Oftentimes in surgery, index complications can initiate a cascade of other problems, resulting in high morbidity and costs,” explains Joseph A. Hyder, MD, PhD.
In the 1980s, the Rule of W mnemonic was first developed to chronicle the most common causes of postoperative fever in the order in which they occur. Although there is some variation in how it is taught, the five W’s are often shared as:
- Wind (atelectasis).
- Water (urinary tract infection [UTI]).
- Wound (wound infection).
- Walking (venous thromboembolism [VTE])
- Wonder drug (drug fever).
“Over time, the Rule of W has undergone numerous variations, but no research has been conducted to establish how the rule was formed or explore its veracity, including whether or not teaching of the rule may be broadened to include patients without fever,” Dr. Hyder says. “These are important shortcomings because multimodal perioperative analgesia, with drugs like acetaminophen and NSAIDs, has become increasingly common to help decrease rates of postoperative fever.”
A Simplified Approach
In a study published in the Journal of Surgical Education, Dr. Hyder and colleagues aimed to develop a simple, evidence-based mnemonic that can be applied to the teaching and diagnosis of postoperative complications. In the study, the timing and relative frequency of common postoperative complications was identified in a diverse surgical population. These findings were then applied to create a mnemonic that is analogous to the Rule of W but with an evidence base and applicability to postoperative patients without fever.
The study consisted of more than 614,000 patients, with nearly 10% of these individuals experiencing index complications of pneumonia, UTI, superficial surgical site infection (sSSI), deep/organ space (dSSI), VTE, kidney injury, and/or myocardial infarction (MI) within 30 days. The median time to complication differed significantly by postoperative day (POD) based on index complications (Figure). “For example, on POD 0, the most common complication was MI,” Dr. Hyder says. “Pneumonia was the most common complication on POD 1 and 2 while pneumonia and UTIs were significantly more common than other complications on POD 3.” On POD 4, the most common complication was sSSI. From POD 5 to POD 30, sSSI and dSSI were the two most common complications. Risk of VTE declined only slightly through POD 30.
A Revised Mnemonic
As a test of timing patterns, the authors calculated the median time to event for each index complication from the Rule of W over 30 days (Table). For additional verification, the median time to complication was tested during the first 14 PODs when competing diagnoses were most dynamic. The median time to events differed significantly during this postoperative interval. Based on the findings, the research team summarized a revision of the Rule of W as follows:
- Waves (ie, electrocardiogram waves)
- Wind (pneumonia)
- Water (UTI)
- Wound (sSSI and dSSI)
- Walking (VTE)
“Our study validates the Rule of W among surgical patients independent of fever and encourages data-driven modifications,” says Dr. Hyder. The revised mnemonic begins with Waves of the electrocardiogram because MI is the most common complication on POD 0. The next complication is still Wind, but this was revised from atelectasis to pneumonia, which represents a new target for prevention, diagnosis, and treatment. There is a striking distinction from the original Rule of W in that VTE was never the most common complication. “Our findings suggest that clinicians should be vigilant about finding VTE because risks for this complication persist 3 to 4 weeks postoperatively,” Dr. Hyder adds.
The more generalized Rule of W suggested in the study may have a role in efforts to prevent cascading complications in surgical patients by promoting prompt diagnosis and early rescue treatments. “Our research can be used as a starting point for critical thinking to enhance training,” Dr. Hyder says. “The findings add confidence to teachers and learners who apply the Rule of W when forming an initial differential diagnosis and creating diagnostic strategies.”
Readings & Resources (click to view)
Hyder JA, Wakeam E, Arora V, Hevelone ND, Lipsitz SR, Nguyen LL. Investigating the “Rule of W,” a mnemonic for teaching on postoperative complications. J Surg Educ. 2015;72:430-437. Available at: http://www.jsurged.org/article/S1931-7204(14)00305-5/abstract.
Hyder JA, Kor DJ, Cima RR, Subramanian A. How to improve the performance of intraoperative risk models: an example with vital signs using the Surgical Apgar Score. Anesth Analg. 2013;117:1338-1346.
Eappen S, Lane BH, Rosenberg B, et al. Relationship between occurrence of surgical complications and hospital finances. J Am Med Assoc. 2013;309:1599-1606.
Cohen ME, Ko CY, Bilimoria KY, et al. Optimizing ACS NSQIP modeling for evaluation of surgical quality and risk: patient risk adjustment, procedure mix adjustment, shrinkage eadjustment, and surgical focus. J Am Coll Surg. 2013;217:336-346.
Stulberg JJ, Delaney CP, Neuhauser DV, Aron DC, Fu P, Koroukian SM. Adherence to surgical care improvement project measures and the association with postoperative infections. J Am Med Assoc. 2010;303:2479-2485.