Inter-rater reliability of the EPUAP pressure ulcer classification system using photographs

Background. Many classification systems for grading pressure ulcers are discussed inthe literature. Correct identification and classification of a pressure ulcer is importantfor accurate reporting of the magnitude of the problem, and for timely prevention.The reliability of pressure ulcer classification systems has rarely been tested.Aims and objectives. The purpose of this paper is to examine the inter-rater reliabilityof classifying pressure ulcers according to the European Pressure Ulcer AdvisoryPanel classification system when using pressure ulcer photographs.Design. Survey was among pressure ulcer experts.Methods. Fifty-six photographs were presented to 44 pressure ulcer experts. Theexperts classified the lesions as normal skin, blanchable erythema, pressure ulcer(four grades) or incontinence lesion. Inter-rater reliability was calculated.Results. The multirater-Kappa for the entire group of experts was 0.80 (P <0.001).Various groups of experts obtained comparable results. Differences in classificationsare mainly limited to 1 degree of difference. Incontinence lesions are most oftenconfused with grade 2 (blisters) and grade 3 pressure ulcers (superficial pressureulcers).Conclusions. The inter-rater reliability of the European Pressure Ulcer AdvisoryPanel classification appears to be good for the assessment of photographs by experts.The difference between an incontinence lesion and a blister or a superficial pressureulcer does not always seem clear.Relevance to clinical practice. The ability to determine correctlywhether a lesion is apressure ulcer lesion is important to assess the effectiveness of preventive measures. Inaddition, the ability to make a correct distinction between pressure ulcers andincontinence lesions is important as they require different preventive measures. Afaulty classification leads to mistaken measures and negative results. Photographs canbe used as a practice instrument to learn to discern pressure ulcers from incontinencelesions and to get to know the different grades of pressure ulcers. The Pressure UlcerClassification software package has been developed to facilitate learning.