Comparison of in-person and digital photograph assessment of stage III and IV pressure ulcers among veterans with spinal cord injuries.

Digital photographs are often used in treatment monitoring for home care of less advanced pressure ulcers. We investigated assessment agreement when stage III and IV pressure ulcers in individuals with spinal cord injury were evaluated in person and with the use of digital photographs. Two wound-care nurses assessed 31 wounds among 15 participants. One nurse assessed all wounds in person, while the other used digital photographs. Twenty-four wound description categories were applied in the nurses' assessments. Kappa statistics were calculated to investigate agreement beyond chance (p < or = 0.05). For 10 randomly selected "double-rated wounds," both nurses applied both assessment methods. Fewer categories were evaluated for the double-rated wounds, because some categories were chosen infrequently and agreement could not be measured. Interrater agreement with the two methods was observed for 12 of the 24 categories (50.0%). However, of the 12 categories with agreement beyond chance, agreement was only "slight" (kappa = 0-0.20) or "fair" (kappa = 0.21-0.40) for 6 categories. The highest agreement was found for the presence of undermining (kappa = 0.853, p < 0.001). Interrater agreement was similar to intramethod agreement (41.2% of the categories demonstrated agreement beyond chance) for the nurses' in-person assessment of the double-rated wounds. The moderate agreement observed may be attributed to variation in subjective perception of qualitative wound characteristics.