Reliability of the European Pressure Ulcer Advisory Panel classification system

AIM: This paper reports a study examining the interrater and intrarater reliability of classifying pressure ulcers according to the European Pressure Ulcer Advisory Panel classification system when using photographs of pressure ulcers and incontinence lesions. BACKGROUND: Pressure ulcer classification is an essential tool for assessing ulcers and their severity and determining which preventive or therapeutic action is needed. Many classification systems are described in the literature. There are only a limited number of studies that evaluate the interrater reliability of pressure ulcer grading scales. The intrarater reliability is seldom studied. METHODS: The study consisted of two phases. In the first phase 56 photographs, together with a random selection of nine photographs from the same set, were presented to 473 nurses. In the second phase, the 56 photographs were presented twice to 86 other nurses with an interval of one month and in a different order. All the nurses were familiar with the European Pressure Ulcer Advisory Panel classification. They did not receive any additional training on classification, and were asked to classify the lesions as normal skin, blanchable erythema, pressure ulcers (four grades, European Pressure Ulcer Advisory Panel classification) or incontinence lesions. RESULTS: In the first phase, the multirater-Kappa for the 473 participating nurses was 0.37 (P < 0.001). Non-blanchable erythema was often confused with blanchable erythema and incontinence lesions. Also incontinence lesions were frequently not correctly classified. The intrarater agreement was low (kappa = 0.38). In the second phase, the interrater agreement was not significantly different in both sessions. The intrarater agreement was 0.52. CONCLUSION: Both the interrater and intrarater reliability of the European Pressure Ulcer Advisory Panel classification of lesion photographs by nurses was very low. Differentiation between pressure ulcers and incontinence lesions seems to be difficult.     

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

Background. Many classification systems for grading pressure ulcers are discussed in the literature. Correct identification and classification of a pressure ulcer is important for 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 reliability of classifying pressure ulcers according to the European Pressure Ulcer Advisory Panel 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. The experts 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 classifications are mainly limited to 1 degree of difference. Incontinence lesions are most often confused with grade 2 (blisters) and grade 3 pressure ulcers (superficial pressure ulcers). Conclusions. The inter‐rater reliability of the European Pressure Ulcer Advisory Panel classification appears to be good for the assessment of photographs by experts. The difference between an incontinence lesion and a blister or a superficial pressure ulcer does not always seem clear. Relevance to clinical practice. The ability to determine correctly whether a lesion is a pressure ulcer lesion is important to assess the effectiveness of preventive measures. In addition, the ability to make a correct distinction between pressure ulcers and incontinence lesions is important as they require different preventive measures. A faulty classification leads to mistaken measures and negative results. Photographs can be used as a practice instrument to learn to discern pressure ulcers from incontinence lesions and to get to know the different grades of pressure ulcers. The Pressure Ulcer Classification software package has been developed to facilitate learning.     

Non-blanchable erythema as an indicator for the need for pressure ulcer prevention: a randomized-controlled trial

Aims and objectives. To evaluate whether postponing preventive measures until non‐blanchable erythema appears will actually lead to an increase in incidence of pressure ulcers (grades 2–4) when compared with the standard risk assessment method. Background. To distinguish patients at risk for pressure ulcers from those not at risk, risk assessment scales are recommended. These scales have limited predictive validity. The prevention of further deterioration of non‐blanchable erythema (grade 1 pressure ulcer) instead of the standard way of assigning prevention could be a possible new approach. Design. Randomized‐controlled trial. Methods. Patients admitted to surgical, internal or geriatric wards (n = 1617) were included. They were randomly assigned to an experimental and a control group. In the experimental group (n = 826), prevention was started when non‐blanchable erythema appeared, in the control group (n = 791) when the Braden score was <17 or when non‐blanchable erythema appeared. In both groups, patients received identical prevention, either by using a polyethylene–urethane mattress in combination with turning every four hours or by using an alternating pressure air mattress. Pressure points were observed daily and classified according to the four grades of the European Pressure Ulcer Advisory Panel. The Braden scale was scored every three days. Results. In the experimental group, 16% of patients received preventive measures, in the control group 32%. The pressure ulcer incidence (grades 2–4) was not significantly different between the experimental (6·8%) and control group (6·7%). Conclusion. Significantly fewer patients need preventive measures when prevention is postponed until non‐blanchable erythema appears and those patients did not develop more pressure ulcers than patients who received prevention based on the standard risk assessment method. Relevance to clinical practice. Using the appearance of non‐blanchable erythema to allocate preventive measures leads to a considerable reduction of patients in need of prevention without resulting in an increase in pressure ulcers.     

National Pressure Ulcer Advisory Panel's updated pressure ulcer staging system

The National Pressure Ulcer Advisory Panel has updated the definition of a pressure ulcer and the stages of pressure ulcers based on current research and expert opinion solicited from hundreds of clinicians, educators, and researchers across the country. The amount of anatomical tissue loss described with each stage has not changed. New definitions were drafted to achieve accuracy, clarity, succinctness, clinical utility, and discrimination between and among the definitions of other pressure ulcer stages and other types of wounds. Deep tissue injury was also added as a distinct pressure ulcer in this updated system.     

Effectiveness of turning with unequal time intervals on the incidence of pressure ulcer lesions

AIM: This paper reports a study investigating whether repositioning patients lying on a pressure-reducing mattress alternately for 2 hours in a lateral position and 4 hours in a supine position reduces the incidence of pressure ulcers in comparison with repositioning every 4 hours. BACKGROUND: Repositioning is commonly recognized as an effective preventive measure. Almost no research has been carried out so far on the necessary turning frequencies to prevent pressure ulcer lesions. The pressure is higher in a lateral than in a supine position. METHOD: A two-arm randomized controlled trial was conducted in 16 Belgian elder care nursing homes. Patients with non-blanchable erythema were randomly assigned to either an experimental or a control group. In the experimental group (n = 122), patients were repositioned alternately 2 hours in a lateral position and 4 hours in a supine position. In the control group (n = 113), patients were repositioned every 4 hours. The sitting protocol was identical in both groups. Pressure areas were observed daily and classified according to the four grades of the European Pressure Ulcer Advisory Panel. RESULTS: In the experimental group, 16.4% patients developed a pressure ulcer lesion (grade 2-4), while 21.2% did so in the control group. The incidence was not statistically significantly different between the two groups (P = 0.40). The severity (P = 0.65) and location (P = 0.19) of pressure ulcer lesions, and the time to developing them (P = 0.29) were also similar in both groups. No patient developed a pressure ulcer at the hips. A considerable number of patients changed from a lateral to a supine position between the turning intervals. CONCLUSION: More frequent repositioning on a pressure-reducing mattress does not necessarily lead to fewer pressure ulcer lesions and consequently cannot be considered as a more effective preventive measure.     

The identification of older nursing home residents vulnerable for deterioration of grade 1 pressure ulcers

Aims and objective. The objective of this study was to identify prognostic factors associated with the development of pressure ulcer lesions (grade 2–4) in nursing home patients with non‐blanchable erythema. Background. No studies could be found that identify risk factors for further development of pressure ulcer in patients with non‐blanchable erythema. For some patients with non‐blanchable erythema, standard preventive measures do not suffice to prevent pressure ulcers from deterioration. Identifying these patients beforehand can considerably contribute to the efficiency of pressure ulcer prevention. Design. Secondary data analyses of a previously conducted randomised controlled trial were performed. Methods. Eighty‐four wards of 16 Belgian nursing homes participated in the study. In total, 235 nursing home residents with a grade 1 pressure ulcer (non‐blanchable erythema) were included. All the residents received standard preventive care. Potential prognostic factors were collected using a standardised form. The incidence of pressure ulcers was recorded according to the European pressure ulcer classification system. Results. The cumulative pressure ulcer incidence was 18·7% (44/235). Hypotension (relative risk = 3·42, 95% CI = 1·56–7·49), a history of a cerebral vascular accident (relative risk = 1·94, 95% CI = 1·10–3·70) and contractures (relative risk = 2·02, 95% CI 1·03–3·95) were identified as independent predictive factors for developing pressure ulcers. Remarkably, being urinary incontinent decreased the risk of developing a pressure ulcer by 76%. Conclusions. In nursing home residents with non‐blanchable erythema, hypotension, contractures, and a history of cerebral vascular accident were independent risk factors for the development of pressure ulcer lesions. Relevance to clinical practice. Patients with non‐blanchable erythema who have hypotension, contractures or a history of cerebral vascular accident are in need of more intensive preventive measures. Identifying these patients can contribute considerably to a more efficient pressure ulcer prevention policy, resulting in a lower pressure ulcer lesion incidence and in lower costs.     

Are patients with or at risk of pressure ulcers allocated appropriate prevention measures?

The aims of the study were to investigate the risk for and prevalence of pressure ulcers in different medical care groups, to discover if patients at risk for or with pressure ulcers are allocated appropriate pressure ulcer preventions and to investigate which variables are associated with appropriate pressure ulcer preventions. A cross-sectional survey design was used and followed the methodology developed by the European Pressure Ulcer Advisory Panel. A total of 612 patients participated in the study. The prevalence of pressure ulcers was greatest in geriatric care, followed by intensive care, acute care and neurological care. The majority of patients at risk for or with pressure ulcers did not receive appropriate preventative measures, either while they were in bed or in a chair. Significant variables associated with appropriate preventions in bed were intensive care, geriatric care, a low Braden score, a low score in the subscale activity and a long hospital stay.     

Treatment of pressure ulcers by serial casting in patients with severe spasticity of cerebral origin.

OBJECTIVE: To assess the effectiveness of serial casting in the treatment of pressure ulcers caused by severe spasticity. DESIGN: Case series. SETTING: A clinic for the rehabilitation of persons with neurologic disorders. PATIENTS: Nine patients with 11 pressure ulcers resulting from severe cerebral spasticity, the ulcers being intractable to conventional management because of repeated friction and/or inaccessibility. INTERVENTION: Serial casting of the limb(s) with the pressure ulcer(s), with either fenestration or a cast arch providing access to the wound. MAIN OUTCOME MEASURES: Improved healing of pressure ulcers, as quantified with the National Pressure Ulcer Advisory Panel classification system. RESULTS: Within a mean of 4.6 weeks, 7 ulcers healed completely and 4 improved markedly. The casting caused no complications. Moreover, extension deficits improved markedly in all patients (105 degrees +/- 27 degrees to 17 degrees +/- 10 degrees ). CONCLUSION: Serial casting may be a valuable tool in the treatment of pressure ulcers at the extremities of patients with severe cerebral spasticity.     

Risky business: Preventing skin breakdown in children with spina bifida

The purpose of this article is to provide an overview of skin issues in children with spina bifida. Included in the discussion below is a review of the etiology of pressure ulcers and the updated 2007 pressure ulcer definition and pressure ulcer staging system as defined by the National Pressure Ulcer Advisory Panel (NPUAP). Pediatric risk factors for skin breakdown are presented including risk factors unique to children with spina bifida. Pediatric pressure ulcer risk assessment scales are described. The 5 Million Lives Kids' Campaign which has a focus on preventing hospital-acquired pressure ulcers in children is also reviewed along with evidence based prevention strategies. The key to preventing skin breakdown and pressure ulcers in children with spina bifida is early identification of the child's individual risk factors so that a prevention protocol can be implemented in all settings: hospital, home and the community. Options for wound management, dressing selection and pain management are included.     

Comparison of pressure ulcer grading scales: a study of clinical utility and inter-rater reliability

Pressure ulcer grading scales are subjective measures of pressure damage. This study measured inter-observer agreement of the Stirling scale (1-digit and 2-digit versions) and the European Pressure Ulcer Advisory Panel Scale, using Cohen's kappa and percentage agreement. Clinical utility was also assessed. Thirty-five observations were made by two Registered Nurses on 30 adult in-patients. The levels of agreement obtained were better than those reported previously and this may be related to the methodology used. The 2-digit Stirling scale gave the best level of chance corrected agreement (kappa=0.457) and was the scale preferred by raters. The 1-digit Stirling scale performed least favourably. Qualitative data identified problems with scale construction relating to visualisation of the base of the wound, discolouration of the skin, abrasions and shallow ulcers. Whilst refinements in scale construction may improve rater reliability, there is a need to develop objective measures of pressure induced tissue damage.     

The first national pressure ulcer prevalence survey in county council and municipality settings in Sweden

Aim To report data from the first national pressure ulcer prevalence survey in Sweden on prevalence, pressure ulcer categories, locations and preventive interventions for persons at risk for developing pressure ulcers. Methods A cross‐sectional research design was used in a total sample of 35 058 persons in hospitals and nursing homes. The methodology used was that recommended by the European Pressure Ulcer Advisory Panel. Results The prevalence of pressure ulcers was 16.6% in hospitals and 14.5% in nursing homes. Many persons at risk for developing pressure ulcers did not receive a pressure‐reducing mattress (23.3–27.9%) or planned repositioning in bed (50.2–57.5%). Conclusions Despite great effort on the national level to encourage the prevention of pressure ulcers, the prevalence is high. Public reporting and benchmarking are now available, evidence‐based guidelines have been disseminated and national goals have been set. Strategies for implementing practices outlined in the guidelines, meeting goals and changing attitudes must be further developed.     

The Effectiveness of Skin Care Protocols for Pressure Ulcers

Pressure ulcers (PU) remain a serious healthcare problem in the United States. This study investigated the effectiveness of a prevention and early intervention program in reducing the prevalence of pressure ulcers (i.e., the number or the percentage of persons with pressure ulcers at a given time) in a rehabilitation hospital. The Braden Scale for Predicting Pressure Sore Risk was used to assess subjects' PU risk. Protocols were established for PU stages consistent with the National Pressure Ulcer Advisory Panel consensus statement on pressure ulcers. Staff were educated about PUs and the specific protocols for prevention and treatment. Concurrent quarterly prevalence audits on a total of 116 patients were conducted for 1 year. An audit also was done 16 months after protocols had been established. There was a 60% decrease in pressure ulcer prevalence from the 25% baseline to the 10% found at the audit following implementation of the protocols.     

The prevalence and incidence of pressure ulcers in hospitalised patients in the Netherlands: a prospective inception cohort study

BACKGROUND: Pressure ulcers frequently occur in hospitalised patients. The prevalence of pressure ulcers grade 2 or worse varies from 3% to 12% in hospitalised patients. Incidence figures are not frequently reported. While incidence and prevalence are both measures of disease frequency, they provide different perspectives on pressure ulcers. OBJECTIVES: To describe the incidence rate and prevalence of pressure ulcers in hospitalised patients. DESIGN: Prospective inception cohort study. SETTING: Two large hospitals, one general (530-beds) and one teaching (1042-beds), in The Netherlands. PARTICIPANTS: A non-selected, though not strictly random, sample of 1536 patients was eligible for inclusion in the study. One thousand four hundred and thirty one patients (93.2%) consented to participate. Eventually, 1229 patients (80%) had a complete follow-up. The sample consisted of patients admitted to the surgical, internal, neurological and geriatric wards for more than 5 days between January 1999 and June 2000. METHODS: Follow-up once a week until pressure ulcer occurrence, discharge or length of stay over 12 weeks. MAIN OUTCOME MEASURES: Occurrence of a pressure ulcer grade 2 or worse during admission to hospital, according to the classification of the European Pressure Ulcer Advisory Panel. RESULTS: One hundred and thirty four patients developed 172 pressure ulcers during follow-up. The overall weekly incidence rate was 0.06 per week (95% confidence interval 0.05-0.07 per week). Highest rates were observed for surgical patients and lowest for geriatric and neurologic patients (0.08 and 0.02, respectively). The week specific prevalence varied between 12.8% and 20.3%. CONCLUSIONS: Among patients hospitalised for more than 5 days overall one may expect 6% per week to develop pressure ulcers. It would appear that any preventive measures can only be effective if taken timely. Accordingly, preventive measures should be considered early, because pressure ulcers were observed already within the first week of admission.     

Histological examination of pressure ulcer tissue in terminally ill cancer patients

Aim: It is a common belief that terminally ill cancer patients have a reduced tissue tolerance that makes them more susceptible than other patients to developing pressure ulcers. However, the actual changes at the tissue level caused by pressure loading in terminally ill cancer patients are unknown, so we examined the relationship between the macroscopic and microscopic features of the tissues of such patients with and without pressure ulcers. Methods: The pressure ulcers of four patients were macroscopically evaluated until the time of death, after which informed consent of the family was obtained to examine the underlying skin tissue histologically. Samples were taken from several sites on the abdomen, which does not experience pressure loading, and from the sacral area. Two of the subjects had no observable pressure ulcers and the other two had a stage I and stage II (National Pressure Ulcer Advisory Panel classification) pressure ulcer, respectively. The samples were processed, stained and examined by using light and transmission electron microscopy. Results: The non‐pressure ulcer samples showed degenerated keratinocytes, leakage of erythrocytes from the capillaries in the dermal papillae, vascular inflammation, and edema. The samples from the stage I and II ulcers had the additional changes of dilated capillaries and vascular inflammation in and around the wound area. Conclusion: Terminally ill cancer patients have damaged skin tissue and inflammation that are not evident by macroscopic examination.     

Pressure ulcer prevention in intensive care patients: guidelines and practice

Background  Pressure ulcers are a potential problem in intensive care patients, and their prevention is a major issue in nursing care. This study aims to assess the allocation of preventive measures for patients at risk for pressure ulcers in intensive care and the evidence of applied pressure ulcer preventive measures in intensive care settings in respect to the European Pressure Ulcer Advisory Panel (EPUAP) and Agency for Health Care Policy and Research (AHCPR) guidelines for pressure ulcer prevention.
Design  The design of this study was a cross-sectional study (point prevalence).
Setting  The study setting was intensive care units. The sample consisted of 169 patients – 60 patients from surgical wards, 59 from interdisciplinary wards and 50 from medical intensive care wards.
Results  The study results revealed that pressure reducing devices like mattresses (alternating pressure air, low air loss and foam) are applied for 58 (36.5%) patients, and all of these patients are at risk for pressure ulcer development. Most patients receive more than one nursing intervention, especially patients at risk. Nursing interventions applied are skin inspection, massage with moisture cream, nutrition and mobility (81.8%, 80.5%, 68.6% and 56.6%) respectively. Moreover, all applied pressure ulcer preventive measures in this study are in line with the guidelines of the EPUAP and AHCPR except massage which is applied to 8.8% of all patients.
Conclusions  The use of pressure reducing devices and nursing interventions in intensive care patients are in line with international pressure ulcer guidelines. Only massage, which is also being used, should be avoided according to the recommendation of national and international guidelines.     

Pressure ulcers--prevention and treatment guidelines

Nurses deal with pressure ulcers on a regular basis, yet much of the research has yet to be put into practice. Lyn Phillips examines the implications of the European Pressure Ulcer Advisory Panel's new guidelines, dealing with prevention and treatment of pressure ulcers.     

A 4-cm thermoactive viscoelastic foam pad on the operating room table to prevent pressure ulcer during cardiac surgery

Aims and objectives. In this experimental study, a 4‐cm thermoactive viscoelastic foam overlay and a heating source on the operating room table was compared with the standard operating room table with a heating source for the effect on the postoperative pressure ulcer incidence in cardiac surgery patients. Background. Pressure ulcer incidence in the cardiac surgery population is reported to be up to 29·5%. The prolonged compressive forces from lying on the operating room table are one source of pressure ulcer development in this population. Pressure‐reducing devices on the operating room (OR)‐table should reduce the patients’ interface pressure and thus the hazard of skin breakdown. Methods. A randomized controlled trial was performed to test the effect of a 4‐cm thermoactive viscoelastic foam overlay with a water‐filled warming mattress on the OR‐table (test OR‐table) compared with the standard OR‐table (a water‐filled warming mattress, no pressure‐reducing device) on the postoperative pressure ulcer incidence in cardiac surgery patients. Instruments. The pressure ulcer classification system of the European Pressure Ulcer Advisory Panel (EPUAP) was used for pressure ulcer grading. Results. The results show that patients lying on the 4‐cm thermoactive viscoelastic foam overlay suffer slightly more pressure ulcer (17·6%) than patients on the standard OR‐table without the foam overlay (11·1%). Because of the clinical relevance of the results, the randomized controlled trial was terminated after 175 patients at the interim analysis although the power calculation stated 350 patients. Conclusions. The combination of a 4‐cm viscoelastic foam overlay and a warming source cannot be recommended for pressure ulcer prevention on the operating room table. Relevance to clinical practice. Foam overlays are used to prevent pressure ulcers in patients. It is necessary to use such devices according to patient safety and use of resources.     

Pressure ulcer prevention and management: the current evidence for care

Pressure ulcers, a common occurrence across healthcare settings, are a costly phenomenon. Since the publication of the AHCPR Guidelines on Pressure Ulcer Prevention and Treatment in the 1990s, additional attention has been focused on pressure ulcer prevention and management. This article discusses current evidence regarding known causes of pressure ulcers, pressure ucler prevention, pressure ulcer classification and assessment, and interventions to effectively manage pressure ulcers.