Surgical Procedures (ASA scores American Society of

Anesthesiologists):-
They established scores for assessment of the physical status of a patient prior to
surgery. These scores are subjective and may be based on incomplete information, so
they are not definitive. There are 6 categories:
1) Normal patient appears to be in good health.
2) Systemic disease is present but is mild.
3) Severe systemic disease
4) Life threatening systemic disease
5) Moribund patient will likely not survive without surgical intervention.
6) Brain-dead patient whose surgery is for the purpose of harvesting organs
The designation of E after ASA score indicates that the surgery is an emergency and
delay might lead to loss of life or body part. However this definition is narrow as
surgery may be to correct sever pain
Category 5 is generally always classified as 5E(surgical need)

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 Wound classification
1- Traditional classification (according to type and risk of infection)
a) Class 1 (clean wounds)
Risk<2%, do not enter an area of the body that is usually colonized by normal flora,
such as urinary or gastrointestinal tracts, there is primary closure and closed
drainage, if necessary, with no break in aseptic technique.
b) Class2 (Clean contaminated wound)
Risk<10% enter into colonized parts of the body (urinary – respiratory tracts) but
elective and controlled not emergency, no break of aseptic technique
c) Class 3 Contaminated wounds)
Risk20% - have obvious inflammation but no purulent discharge. They may involve
spillage of the gastrointestinal tract, penetrating wounds (<4 hours), substantial
break of aseptic technique
d) Class 4 (Dirty-infected wounds)
Risk 40% - obvious inflammation and purulent discharge, There may be penetration
of viscera prior to surgery – penetrating wound >4 hours

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 T-point classification system
It assigns time in hours based on information in the NNIS database about average
length of surgery. The assigned T point for surgical procedures in the number of
hours that equal the 75% percentile. Thus, a T point of 5 means that 75% of these
types of surgery are completed within 5 hours. exceeding the T point increase the
risk of infection or complications, so this system is used as one aspect of evaluation of
surgical site infection risk although time is only one variable and should not be
considered in isolation of other risk factors may be of more importance

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 CDC/NNIS Risk Index system
It is created to standardize reporting of data regarding wound infections/ The risk
Index integrates the traditional, T point, and ASA classifications. The risk index
score range from 0-3 with a point for each of the applicable variables based on the
other classifications
0 Point……. No Risk factor
1 Point… Score of 3 or 4 on the traditional classification (contaminated or dirty
1 Point…...Score of 3, 4 or 5 on the ASA classification
1 Point… Score Exceeds the T point duration for this type of operation
N.B Even with zero point some risk of infection still exists but the predictive
percentage rate for surgical site infections increase with the risk index score.

A surgical risk index is a score used to predict a surgical patient's

risk of acquiring an SSI. The risk index score. ranging from 0 to 3, is
the sum
of the number of risk factors present among the following:
• A patient with an ASA physical status classification score of 3, 4, or 5
• An operation classified as contaminated or dirty/infected
• An operation lasting longer than the duration cut point in minutes,

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 where the duration cut point varies by the type of operative
procedure performed

likely develop infection (percentage)

1.5% 0 score
2.9% 1 score
6.8% 2 score
13.0 3 score

Surgical site infection definitions

Category1: the first category (superficial incision infection,) which occurs within 30
days of surgery and involves only skin and subcutaneous tissue of the Incision. The patient
has one of the following:
-Purulent drainage- Organisms isolated from culture of wound fluid or tissue -Localized
sign of infection -Diagnosis of Superficial infection by surgeon or attending physician.
Category2 (Deep incision) may include those wounds that have both superficial and deep
incision characteristics. These occur within 30 days of surgery if there is no implant or 1

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 year if an implant is in place. Infection appears related to the surgery and involves deep
soft tissues (fascial and muscle layers) of the incision, and patient has one of the following:
-purulent drainage from incision.
-Spontaneous opening of wound or deliberately opened by surgeon when patient has one of
these symptoms: fever (38C) -localized -pain or tenderness, unless wound culture is
negative
-Abscess or other evidence of incision infection found on direct examination, or histopathology.
-Diagnosis of a deep incisional infection by surgeon or attending physician.
Category 3 (Organ Space) It occur within 30 days of surgery if no implant or one year if
implant in place. Infection appears related to surgery and involves any part of the body,
excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during
the operative procedure. Patient has one of the following:
-Purulent drainage from a drain that is placed through a slab wound into the organ/space
-Organisms isolated from an aseptically obtained culture of fluid or tissue in the
organ/space
-An abscess or other evidence of infection involving the organ/space that is found on
direct examination, during reoperation, or by histopathology or radiology,
-Diagnosis of an organ/ space infection by surgeon or attending physician.

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 Rates of events calculation
- When calculating rates of events (infection, death, disease), the formula requires a numerator,
which is the targeted event (such as surgical site infections) and denominator, which is the pool (such
as the number of patients receiving surgery). The NaSH has established standardized
numerator/denominator formulas. The procedure-associated formula:
Numerator…. SSI
Denominator…1) Inpatients and outpatients undergoing operative procedures.
2) Specific Risk factors for certain procedures
- This new formula takes into account risk factors, which can include the ASA number,
the wound classification, the T point, or the risk index. The denominator data could
include, for example, only those with ASA scores of 3,4,or5 but that ignores other
variables. The results should be adjusted according to risk factor data.

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