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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.

Accurate identification of nonblanchable erythema (NBE) is essential in pressure ulcer prevention. This descriptive study assessed interrater reliability between a researcher and trained nurses in observing blanchable erythema and NBE and examined the predictive validity and level of agreement between two observation methods for NBE. Findings suggest that the transparent disk method should be preferred to the finger method. The interrater reliability between the researcher and the nurses was substantial and was higher for the observations at the sacrum than for those at the heels. Educational level and years of nursing experience did not seem to influence interrater reliability.

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. [ABSTRACT FROM AUTHOR]

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 suggested. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]