In Focus: Uses and Limitations with Using Digital Photography for Pressure Ulcer Staging in the Acute Care Setting

Purpose:
The aim of this study was to examine whether a digital photo could reliably convey the characteristics of a pressure ulcer. Multirater agreement was used to compare a bedside assessment of a pressure ulcer by a certified wound nurse with the assessment of the same wound by a panel of experts.

Background/Significance:
Digital photography of wounds is proposed as a method to document pressure ulcers for forensic cases, protect against legal disputes, and for treatment management. Most studies on wound photography occur in home care and long-term care settings. In view of the somewhat untested practice of using wound photography in the acute care setting, and compelling need to graphically document the presence of pressure ulcers in today's healthcare environment, a funded research study was conducted.

Methods:
This multisite non-experimental study compared bedside assessment of wound characteristics and staging of 100 pressure ulcers by a certified Wound Ostomy Continence Nurse (CWOCN) with the assessment of the same wound by an expert panel of 3 certified CWOCNs via digital photography. This study examined thirteen wound characteristics and a total score on the Bates-Jensen Wound Assessment Tool (BWAT) as well as the staging of a pressure ulcer using the National Pressure Ulcer Advisory Panel (NPUAP) definitions. A non-probability sampling plan used a convenience sample of 69 adult inpatients at the two hospitals to obtain photographs of 100 pressure ulcers.

Results:
Only fair to moderate levels of agreement were found between scores for the BWAT 13 characteristics of the bedside assessment and the digital photo assessment and between NPUAP stages of the bedside assessment and the digital photo assessment. DTIs and unstageable pressure ulcers had the highest levels of agreement whereas stage 1 pressure ulcers had the lowest. These data suggest DTIs and unstageable pressure ulcers were the most accurately depicted in the digital photos. Consistent with these findings, moderate levels of agreement were also noted for distinguishing necrotic tissue type and amount which are hallmarks of unstageable pressure ulcers.

Conclusions and Implications for Practice:
Systems designed to provide digital photography wound measurements may augment reliability. The development of standardized education for examining digital photographs may also increase rater agreement Findings from the study can serve as a foundation for developing hospital digital photo protocols.