• Khalid Munir Bhatti Health Education of England
  • Basem Hamzah North Cumbria Integrated Care, Carlisle,
  • Shafiq Rehman North Cumbria Integrated Care, Carlisle
  • Emily Birkett North Cumbria Integrated Care, Carlisle
  • Wren Langford North Cumbria Integrated Care, Carlisle
  • Myat Aung Consultant Colorectal Surgeon North Cumbria integrated care
  • Ruben Canelo Consultant Surgeon & Professor of surgery North Cumbria integrated care University of Central Lancashire, UK


Background: Current study documents the role of Age adjusted Charlson Comorbidity Index (ACCI) as a stratification tool for the development of postoperative SARS-CoV-2 infection in surgical patients. Methods: This prospective cohort study was conducted over the period of 8 weeks starting on 1st of March 2020. Sampling was convenience and purposive and included all consecutive patients who underwent any surgical procedure. Follow up period was 30 days. Outcomes included postoperative SARS-CoV-2 infection, morbidity and 30-day mortality. Risk factors for development of infection were detected by univariate and multivariate analysis.  Results: Postoperative SARS-CoV-2 infection developed in 37 cases while 131cases remained confirmed negative. Of 37 patients, 18 were male while 19 were female. Postoperative complications developed in 17 patients (45.9%). In-hospital 30-day mortality was 16.2% (n=6). The factors that increased the chances of postoperative SARS-CoV-2 infection (p<0·00) included increasing age, higher ACCI Score, emergency surgery, trauma, orthopaedic and vascular procedures, spinal anaesthesia, and surgeries of complex nature. In adjusted analyses, predictors of postoperative infection included ACCI score of 4 or more (5.54 [1·51–20.34], p<0·01), and orthopaedics or vascular procedures versus others (12.32 [1.98-76.46], p<0·007). Based on infection rates across the different scores of ACCI, cohort was divided into 3 groups. ACCI score of zero had postoperative SARS-CoV-2 infection rate of 1.9 % (negative predictive value, 98.1%) compared with 36.26% in patients with score of 4 or more (sensitivity, 89.19%). Conclusion: Low risk surgical patients (ACCI=0) should have universal precautions, while intermediate risk group (ACCI=1-3) should have extra precautions. The options for high-risk patients (ACCI ≥4) include cancellation of nonurgent surgery; delaying the surgery till optimization of modifiable factors; or reverse isolation/ shielding in perioperative period if surgery cannot be cancelled.

Author Biography

Khalid Munir Bhatti, Health Education of England

Higher Speciality Trainee, Surgery


Nahshon C, Bitterman A, Haddad R, Hazzan D, Lavie O. Hazardous postoperative outcomes of unexpected covid-19 infected patients: A call for global consideration of sampling all asymptomatic patients before surgical treatment. World J Surg 2020;44(8):2477–81.

COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet 2020;396(10243):27–38.

Doglietto F, Vezzoli M, Gheza F, Lussardi GL, Domenicucci M, Vecchiarelli L, et al. Factors associated with surgical mortality and complications among patients with and without coronavirus disease 2019 (COVID-19) in Italy. JAMA Surg 2020;155(8):691–702.

Du RH, Liang LR, Yang CQ, Wang W, Cao TZ, Li M, et al. Predictors of mortality for patients with COVID-19 pneumonia caused by SARS-CoV-2: a prospective cohort study. Eur Respir J 2020;55(5):2000524.

Tian W, Jiang W, Yao J, Nicholson CJ, Li RH, Sigurslid HH, et al. Predictors of mortality in hospitalized COVID-19 patients: A systematic review and meta-analysis. J Med Virol 2020;92(2):1875–83.

Ruan Q, Yang K, Wang W, Jiang L, Song J. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med 2020;46(5):846–8.

Knight SR, Ho A, Pius R, Buchan I, Carson G, Drake TM, et al. Risk stratification of patients admitted to hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: development and validation of the 4C Mortality Score. BMJ 2020;370:m3339.

Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83.

Suidan RS, Leitao MM Jr, Zivanovic O, Gardner GJ, Long Roche KC, Sonoda Y, et al. Predictive value of the Age-Adjusted Charlson Comorbidity Index on perioperative complications and survival in patients undergoing primary debulking surgery for advanced epithelial ovarian cancer. Gynecol Oncol 2015;138(2):246–51.

Charlson M. MD+CALC. Charlson Comorbidity Index (CCI). [Internet]. [cited 2020 Aug 10]. Available from:

Yang CC, Chen PC, Hsu CW, Chang SL, Lee CC. Validity of the age-adjusted Charlson comorbidity index on clinical outcomes for patients with nasopharyngeal cancer post radiation treatment: a 5-year nationwide cohort study. PLoS One 2015;10(1): e0117323.

Robbins JR, Gayar OH, Zaki M, Mahan M, Buekers T, Elshaikh MA. Impact of age-adjusted Charlson comorbidity score on outcomes for patients with early-stage endometrial cancer. Gynecol Oncol 2013;131(3):593–7.

Skierka AS, Michels KB. Ethical principles and placebo-controlled trials - interpretation and implementation of the Declaration of Helsinki's placebo paragraph in medical research. BMC Med Ethics 2018;19(1):24.

Copeland G. MD+CALC. POSSUM for Operative Morbidity and Mortality Risk. [Internet]. [cited 2020 Aug 10]. Available from:

de Groot V, Beckerman H, Lankhorst GJ, Bouter LM. How to measure comorbidity. a critical review of available methods. J Clin Epidemiol 2003; 56:221–9.

Austin SR, Wong YN, Uzzo RG, Beck JR, Egleston BL. Why summary comorbidity measures such as the Charlson comorbidity index and Elixhauser score work. Med Care 2015;53(9): e65–72.

Sun Y, Koh V, Marimuthu K, Ng OT, Young B, Vasoo S, et al. National Centre for Infectious Diseases COVID-19 Outbreak Research Team: epidemiological and clinical predictors of COVID-19. Clin Infect Dis 2020; 71:786–92.

The Royal College of surgeons of England. New and Events. Covid ‘wrecking ball’ through NHS waiting times. [Internet]. [cited 2020 Sep 29]. Available from:

Spolverato G, Capelli G, Restivo A, Bao QR, Pucciarelli S, Pawlik TM, et al. The management of surgical patients during the coronavirus disease 2019 (COVID-19) pandemic. Surgery 2020;168(1):4–10.

Holman N, Knighton P, Kar P, O'Keefe J, Curley M, Weaver A, et al. Risk factors for COVID-19-related mortality in people with type 1 and type 2 diabetes in England: a population-based cohort study. Lancet Diabetes Endocrinol 2020;8(10):823–33.

Bláha M, Vanásek J, Mĕrka V, Splino M, Malý J, Siroký O. Clinical use of reverse isolation in a protected environment. Folia Microbiol (Praha) 1979;24(1):88–95.

The Vascular and Endovascular Research Network Vern Executive Committee. The COvid-19 Vascular sERvice (COVER) Study: An International Vascular and Endovascular Research Network (VERN) collaborative study assessing the provision, practice, and outcomes of vascular surgery during the covid-19 pandemic. Eur J Vasc Endovasc Surg 2020;60(1):156–7.

D'Ambrosi R. Orthopedics and COVID-19: Scientific Publications Rush. Indian J Orthop 2020;54(Suppl 2):1–7.