Issues Related to Accurate Classification of Buttocks Wounds

Abstract

Accurate wound classification impacts not only treatment decisions but also reimbursement, risk of litigation, and accuracy of data regarding prevalence and incidence of pressure ulcers. It is, therefore, critical for professional societies such as the WOCN to begin development of consensus definitions and guidelines to ensure consistency and accuracy in wound classification.

Incontinence-Associated Dermatitis

“…Preintervention scores revealed low accuracy in classifi cation; scores improved signifi cantly following educational intervention. The levels of agreement prior to the educational program are consistent with those of Mahoney's group, 10 who conducted a study in the United States evaluating the level of agreement among WOC nurses when asked to classify pressure, moisture and mix moisture, and pressure lesions based on photographs; they reported an overall kappa score of 0.1708. …”

“…However, members of the IAD consensus document concur that misclassifi cation is a problem, for several reasons: (1) effective treatment of any type of skin breakdown must include correction of etiologic factors, and measures to protect against prolonged pressure are quite different from those designed to correct exposure to urine and stool; (2) misclassifying IAD as a pressure ulcer increases the agency's risk for litigation, since pressure ulcers are now considered to be medical errors; (3) misclassifi cation of IAD lesions as pressure ulcers compromises the integrity and validity of prevalence and incidence data and makes meaningful benchmarking impossible; and (4) incorporation of IAD lesions in pressure ulcer prevalence data prevents accurate measurement of the prevalence and incidence of both conditions and does not allow comparison of data for benchmarking purposes. 10 Given differences in etiology and pathophysiology, accurate classifi cation of IAD versus pressure ulceration appears straightforward on initial consideration. Pressure ulcers are ischemic lesions, caused by tissue and vessel deformation that leads to progressive tissue hypoxia and death.…”

“…Pressure ulcers are characterized as bottom-up injuries, because they originate in deep tissue layers and progress toward the surface. [10][11][12] They typically present as full-thickness wounds located over bony prominences or under medical devices, are characterized by signifi cant tissue necrosis and tissue loss, and are often associated with undermining and tunneling. 3,13,14 In contrast, IAD is an infl ammatory response to prolonged exposure of the skin to stool and/or urine; the lesions are characterized as topdown injuries that initially present as erythema of intact skin but may progress to vesicle formation and epidermal loss, especially when the area is also exposed to friction.…”

“…Consistently accurate differential assessment requires agreement among clinicians regarding the pathology and presentation of pressure ulcers, IAD, ITD, and mixed lesions, and current data indicate that obtaining consensus on these issues will be a major challenge. Results of studies based in the United States and Europe 5,6,9,10,25 consistently reveal that accurate classifi cation remains a challenge. A consensus session sponsored by the WOCN Society revealed that inclusion of partial-thickness lesions in the NPUAP staging system for pressure ulcers contributes signifi cantly to confusion among clinicians.…”

Incontinence-Associated Dermatitis

“…Finally, correct identifi cation of skin damage infl uences classifi cation when measuring national or international benchmark data for quality-sensitive indicators such as facility-acquired pressure ulcers. 39 The 2005 consensus group identifi ed several characteristics designed to aid clinicians in differentiating IAD from skin tears or various categories of pressure ulcers ( Table 3 ). 1 Black and colleagues 4 included a table in their second consensus statement that provides a useful guide for differentiating IAD from stage I and II pressure ulcers.…”