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

J Clin Nurs. 2004 Nov;13(8):952-9. doi: 10.1111/j.1365-2702.2004.00974.x.


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.

Publication types

  • Evaluation Study

MeSH terms

  • Adult
  • Female
  • Humans
  • Male
  • Middle Aged
  • Observer Variation
  • Photography
  • Practice Guidelines as Topic*
  • Pressure Ulcer / classification*
  • Pressure Ulcer / pathology*
  • Reproducibility of Results