Classification of pressure ulcers: a systematic literature review

Different classifications of pressure ulcer are in use making national and international studies on epidemiological issues as well as on effects of prophylactical and therapeutical interventions difficult. A systematic literature search identified 31 pressure ulcer classifications. Thirteen could be retrieved and were further analyzed. Six variants of the International Classification of Diseases (ICD) differ totally in number of classes, hierarchical structure, characteristics included, and level of detail. They share only the fact of a "pressure ulcer". Recommendations of expert organizations and clinical classifications differ as well. The currently introduced grade "suspected deep tissue injury" in the classification proposed by the US-National Pressure Ulcer Advisory Panel (NPUAP) is neither present in the European Pressure Ulcer Advisory Panel (EPUAP) one, nor in the ICD variants. Being aware of the reliability issue in pressure ulcer diagnosis and grading, the situation is appalling. Furthermore, stage adjusted quality assessment, prophylaxis and therapy ends with the borders of a classification. We call the WHO to initiate a harmonization of the ICD variants of pressure ulcer classification and to cooperate with experts' organizations in this field, particularly with regard to the development of ICD-11. Reports on pressure ulcer should always mention the classification used.