How accurate are pressure ulcer grades? An image-based survey of nurse performance

J Tissue Viability. 2001 Apr;11(2):67, 70-5. doi: 10.1016/s0965-206x(01)80028-0.


We report a descriptive study using a questionnaire and twelve digital photographs classified by a consensus panel of experts using the European Pressure Ulcer Advisory Panel and Stirling plus digits classifications. The expert panel comprised 5 tissue viability specialists/clinical lecturers in tissue viability with many years of collective experience and examined 30 images over 2 1/2 hours. In general consensus on wound grading was good; in only 2 images was there insoluble disagreement. Two hundred subjects were recruited from a Tissue Viability Society (N = 50), the European Pressure Ulcer Advisory Panel (N = 50), five Community Trusts (N = 50) and five Acute Trust (N = 50) in England and Wales. The subjects were asked for demographic details (qualifications achieved, number of years qualified, employment grade and how their knowledge of classification of pressure ulcers has been obtained). The second part of the questionnaire asked them to classify twelve digital photographs of pressure ulcers using the European Pressure Ulcer Advisory Panel (EPUAP) and the Stirling plus digits systems. The study demonstrated that there is considerable lack of consensus when pressure ulcers are graded using the Stirling plus digit grading system and less disagreement when the EPUAP scale is used. The study also demonstrates that the statistical returns from different hospital and community units cannot be considered to be directly comparable. Furthermore, the study showed that the nurses most educated in pressure ulcer care (Clinical Nurse Specialists in Tissue Viability) were the most keen to receive extra education, whilst ward nurses were happy with their current knowledge and did not believe further education on pressure ulcer grading was necessary.

Publication types

  • Evaluation Study

MeSH terms

  • Health Knowledge, Attitudes, Practice*
  • Humans
  • Nursing Staff, Hospital*
  • Observer Variation
  • Photography
  • Pressure Ulcer / classification*
  • Pressure Ulcer / nursing
  • Pressure Ulcer / pathology
  • Professional Competence
  • Reproducibility of Results
  • Severity of Illness Index
  • Surveys and Questionnaires