EPUAP classification system for pressure ulcers: European reliability study

Authors

  • Dimitri Beeckman,

    1. Dimitri Beeckman MA RN PhD Candidate Nursing Science, Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University and Research Staff, Nursing Department, University College Arteveldehoge-school, Belgium
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  • Lisette Schoonhoven,

    1. Lisette Schoonhoven PhD RN Assistant Professor Nursing Science, Centre for Quality of Care Research (WOK), Radboud University Nijmegen Medical Centre, The Netherlands
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  • Jacqui Fletcher,

    1. Jacqui Fletcher BSc RN Principal Lecturer School of Nursing and Midwifery, University of Hertfordshire, Hatfield, UK
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  • Kátia Furtado,

    1. Kátia Furtado MA RN Community Nursing Specialist Centro de Saúde de Arronches, Portalegre, Portugal
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  • Lena Gunningberg,

    1. Lena Gunningberg PhD RN Leader of Nursing Research and Development Surgery Division, Uppsala University Hospital and Assistant Professor, Department of Surgical Science, Uppsala University, Sweden
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  • Hilde Heyman,

    1. Hilde Heyman RN Nursing Director Nursing Home Sint Bartholomeus, Antwerp, Belgium
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  • Christina Lindholm,

    1. Christina Lindholm PhD RN Professor Department of Clinical Nursing, Kristianstad University, Kristianstad, Sweden
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  • Louis Paquay,

    1. Louis Paquay MSc RN Nursing Coordinator Wit-Gele Kruis van Vlaanderen, Brussels, Research Staff, Academic Centre for General Practice, Kuleuven, Belgium
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  • José Verdú,

    1. José Verdú PhD RN Senior Lecturer Nursing Science, Department of Community Nursing, Preventive Medicine, Public Health and History of Science, School of Nursing, University of Alicante, Alicante, Spain
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  • Tom Defloor

    1. Tom Defloor PhD RN Professor Nursing Science, Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium
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D. Beeckman: e-mail: dimitri.beeckman@ugent.be

Abstract

Title. EPUAP classification system for pressure ulcers: European reliability study

Aim.  This paper is a report of a study of the inter-observer reliability of the European Pressure Ulcer Advisory Panel pressure ulcer classification system and of the differential diagnosis between moisture lesions and pressure ulcers.

Background.  Pressure ulcer classification is a valuable tool to provide a common description of ulcer severity for the purposes of clinical practice, audit and research. Despite everyday use of the European Pressure Ulcer Advisory Panel system, its reliability has been evaluated in only a limited number of studies.

Methods.  A survey was carried out between September 2005 and February 2006 with a convenience sample of 1452 nurses from five European countries. Respondents classified 20 validated photographs as normal skin, blanchable erythema, pressure ulcers (four grades), moisture lesion or combined lesion. The nurses were familiar with the use of the European Pressure Ulcer Advisory Panel classification scale.

Results.  Pressure ulcers were often classified erroneously (κ = 0·33) and only a minority of nurses reached a substantial level of agreement. Grade 3 lesions were regularly classified as grade 2. Non-blanchable erythema was frequently assessed incorrectly as blanchable erythema. Furthermore, the differential diagnosis between moisture lesions and pressure ulcers appeared to be complicated.

Conclusion.  Inter-observer reliability of the European Pressure Ulcer Advisory Panel classification system was low. Evaluation thus needs to focus on both the clarity and complexity of the system. Definitions and unambiguous descriptions of pressure ulcer grades and the distinction between moisture lesions will probably enhance clarity. To simplify the current classification system, a reduction in the number of grades is suggested.

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