EPUAP classification system for pressure ulcers: European reliability study
Beeckman, D × Schoonhoven, L Fletcher, J Furtado, K Gunningberg, L Heyman, H Lindcolm, C Paquay, Louis Verdu, J Defloor, T #
Blackwell Scientific Publ.
Journal of Advanced Nursing vol:60 issue:6 pages:682-691
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. Asurvey 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 (j = 0Æ33) 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