Pressure Ulcer Education Improves Interrater Reliability, Identification, and Classification Skills by Emergency Nurses and Physicians

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Pressure ulcers (PUs) are a serious health complication that develop as a result of pressure alone or pressure in combination with shearing forces. Although PUs are typically associated with older adults and chronic illness, acutely injured trauma patients may have a particular risk for the development of PUs. To prevent PU development or detect PUs in an early stage, skin assessment and PU classification should start during the ED stay, before hospital admission. The aim of this study was to assess the PU identification and classification skills of emergency nurses and emergency physicians and to evaluate the short-term effect of an educational intervention.


Twenty validated photographs were used to test identification and classification skills in a one-group pretest/posttest design, before and after an educational intervention with 54 emergency nurses and physicians. In addition, we assessed the interrater reliability of PU identification and classification.


PU identification and classification skills and the multirater κ improved after the educational intervention. Accurate identification improved significantly from 87.7% to 95.6% (P = .000), and classification skills improved significantly from 68.5% to 79.8% (P = .000). The multirater κ for identification of PU increased from 0.63 to 0.82, and the multirater κ for classification of PUs rose from 0.43 to 0.58. The most frequently misclassified photographs were those that displayed category 1, 2, and 3 PUs, which were usually classified as more severe.


This study investigated the effect of an educational intervention on the interrater reliability, PU identification, and PU classification skills of emergency nurses and physicians when tested immediately after the intervention. Study results show that interrater reliability, PU identification, and PU classification of photographs all improved, but identifying the presence of a PU in a photograph was less challenging than categorizing the same wound.

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