EPUAP classification system for pressure ulcers: European reliability study

EPUAP classification system for pressure ulcers: European reliability studyAim. This paper is a report of a study of the inter-observer reliability of theEuropean Pressure Ulcer Advisory Panel pressure ulcer classification system and ofthe differential diagnosis between moisture lesions and pressure ulcers.Background. Pressure ulcer classification is a valuable tool to provide a commondescription of ulcer severity for the purposes of clinical practice, audit and research.Despite everyday use of the European Pressure Ulcer Advisory Panel system, itsreliability has been evaluated in only a limited number of studies.Methods. Asurvey was carried out between September 2005 and February 2006 witha convenience sample of 1452 nurses from five European countries. Respondentsclassified 20 validated photographs as normal skin, blanchable erythema, pressureulcers (four grades), moisture lesion or combined lesion. The nurses were familiarwith the use of the European Pressure Ulcer Advisory Panel classification scale.Results. Pressure ulcers were often classified erroneously (j = 0Æ33) and only aminority of nurses reached a substantial level of agreement. Grade 3 lesions wereregularly classified as grade 2. Non-blanchable erythema was frequently assessedincorrectly as blanchable erythema. Furthermore, the differential diagnosis betweenmoisture lesions and pressure ulcers appeared to be complicated.Conclusion. Inter-observer reliability of the European Pressure Ulcer Advisory Panelclassification system was low. Evaluation thus needs to focus on both the clarity andcomplexity of the system. Definitions and unambiguous descriptions of pressure ulcergrades and the distinction between moisture lesions will probably enhance clarity. Tosimplify the current classification system, a reduction in the number of grades issuggested.