Introducing a new validated Skin Tear Classification System

Abstract

The appropriate management of patients with skin tears is an ongoing challenge for healthcare professionals. Skin tears are painful, acute wounds resulting from trauma to the skin and are largely preventable. Despite preliminary studies that suggest skin tears may be more prevalent than pressure ulcers, there remains a paucity of literature to guide prevention, assessment, and treatment of skin tears. Payne and Martin (1993) established a classification system however it failed to become universally accepted and an international survey by LeBlanc and Baranoski (2010) indicated that healthcare professionals would like a more simplistic classification system.

In an effort to shift awareness towards this largely unheeded healthcare issue, an International Skin Tear Advisory Panel (ISTAP) was established. 13 internationally recognized key opinion leaders convened to establish consensus statements on the prevention, prediction, assessment and treatment of skin tears. The initial ISTAP meeting was held in January 2011, and was made possible by an unrestricted educational grant from Hollister Wound Care Inc. The meeting resulted in the development and publication of 12 key consensus statements and a definition for skin tears.

A follow up ISTAP meeting in December 2011, resulted in the development of a new classification system building on the work of Payne and Martin (1993). The ISTAP Skin Tear Classification System was validated for internal, external and intra-reliability with 86% agreement. Kappa testing was conducted according to the Landis and Koch interpretation and demonstrated substantial agreement (Fleiss Kappa =0.619).

The development of a universally accepted classification system for skin tears is an important first step towards developing international guidelines for the prevention, prediction, assessment and management of skin tears. It is essential that these wounds be distinguished from other wound types in order to reach this goal and to raise the global awareness of these unique wounds.

Full text

Validation of a New Classification
System for Skin Tears
Kimberly LeBlanc, MN, RN, CETN(C) IIWCC; Sharon Baranoski, MSN, RN, CWCN, APN-CCNS, MAPWCA, FAAN;
Samantha Holloway, MSc, RN; and Diane Langemo, PhD, RN, FAAN
ABSTRACT
OBJECTIVE: The aim of this study was to validate and establish
reliability of the International Skin Tear classification system.
METHOD: A consensus panel of 12 internationally recognized
key opinion leaders convened in 2011 to establish consensus
statements on the prevention, prediction, assessment, and
treatment of skin tears. Subsequently, a new skin tear
classification system was proposed. The system was then tested
for interrater and intrarater reliability between the experts
before being tested more widely on a sample of 327 individuals
from the United States, Canada, and Europe.
RESULTS: The results of the study indicated a substantial level
of agreement for the expert panel (Fleiss
J
= 0.619; 2-month
follow-up = 0.653). Intrarater reliability was high (Cohen
J
= 0.877). Interrater reliability was moderate (Fleiss
J
= 0.555)
for healthcare professionals (n = 303) and fair for nonYhealth
professionals (Fleiss
J
= 0.338; n = 24).
CONCLUSIONS: This international study established the reliability
and validity of a new classification system for skin tears.
KEYWORDS: skin tears, classification, reliability, and validity
ADV SKIN WOUND CARE 2013;26:263Y65
BACKGROUND
Skin tears (STs) are often painful, acute wounds resulting from
trauma to the skin, and they are largely preventable.
1Y6
When
assessing STs, it is important to classify the extent of injury to
guide management. Payne and Martin
7
established the first
classification system; however, this system failed to become uni-
versally accepted. Almost 2 decades later, Carville et al
8
es-
tablished the Skin Tear Audit Research system. Yet, neither
of these systems gained widespread acceptance. An interna-
tional survey in 2011 by LeBlanc et al
9
indicated a preference by
healthcare professionals for a user-friendly, simple classification
system.
In an effort to redirect awareness toward this largely unheeded
healthcare issue, an International Skin Tear Advisory Panel
(ISTAP) (Table 1) of 12 internationally recognized key opinion
leaders convened to establish consensus statements on the pre-
vention, prediction, assessment, and treatment of STs. This re-
sulted in the development and publication of 12 key consensus
statements and a definition for STs.
10
Asubsequentmeeting
of the ISTAP in December 2011 resulted in the development of
a new classification system based on existing sytems.
7,8
Content
validity was established based on a thorough review of the ST
classification literature.
METHODS
The ISTAP consensus panel defined ST as follows: ‘‘A skin tear is a
wound caused by shear, friction, and/or blunt force, resulting in
separation of skin layers. A skin tear can be partial-thickness
(separation of the epidermis from the dermis) or full-thickness
(separation of both the epidermis and dermis from underlying
structures).’’
10
Initially, the ISTAP group developed 12 consensus statements
for the prevention, prediction, assessment, and treatment of STs.
10
This was supplemented with the development of the ISTAP clas-
sification system. To achieve the goal of simplicity, 3 types of STs
were identified and described (Figure 1).
The panel members submitted 74 ST photographs. The ISTAP
members collected the digital photographs with consent, based
on their healthcare setting’s policies and procedures. Individual
subjects or their spokesperson consented to the photographs be-
ing used for the classification validation study and for teaching
purposes in the future. No individual identifiers were visible in
the photographs. Photographs that were previously taken with
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Kimberly LeBlanc, MN, RN, CETN (C) IIWCC, is a Consultant, KDS Professional Consulting, Ottawa, Ontario, Canada. Sharon Baranoski, MSN, RN, CWCN, APN-CCNS, MAPWCA, FAAN,
is President, Wound Care Dynamics Inc, Shorewood, Illinois. Samantha Holloway, MSc, RN, is Senior Lecturer/Course Director in Wound Healing and Tissue Repair, Wound Healing
Research Unit, Institute for Translation, Innovation, Methodology and Engagement, School of Medicine, Cardiff University, United Kingdom. Diane Langemo, PhD, RN, FAAN, is President
and Consultant, Langemo & Associates, University of North Dakota, Grand Forks. Ms LeBlanc has disclosed that she is a consultant to and member of the speaker’s bureau for Hollister,
Mo¨ lnlycke, and Systagenix; and has received grant funding from Hollister. Ms Baranoski has disclosed that she is a member of the advisory board for Mo¨ lnlycke and is a consultant and a
member of the speaker’s bureau for Hollister Wound Care and KCI. Ms Holloway has disclosed that she has no financial relationships related to this article. Dr Langemo has disclosed that
she is a consultant to EHOB, Inc; has received grant funding from Medline; has been a member of the speaker’s bureau for Hill-Rom; has received reimbursement for manuscript
preparation from Medline; and has received reimbursement for development of educational presentation and travel expenses from Hill Rom. Acknowledgment: MsLeBlanc and Ms Baranoski
acknowled ge the contribution of Keryln Carville, R N, PhD, Associate Pr ofessor, Domicili ary Nursing, Silve r Chain Nursing Ass ociation and Curtin U niversity, Pert h, Australia, for her i nitial
work as part of the Int ernational Skin Tear A dvisory Panel. Submit ted January 30, 2013; acc epted March 1, 2013.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

informed consent and that were the property of an ISTAP team
member were accepted into the photograph bank with copyright
assigned to the ISTAP group. One researcher (K.L.) selected the
highest-quality photographs with equal representation of the 3
types to test the internal validity of the classification system (n = 30).
The photographs were then distributed to the panel members
to internally validate the proposed Skin Tear Classification Sys-
tem. The panelwas directed to classify the 30 test photographs by
type of STs without referring to the classification document to
blind the participants and test the simplicity of the classification
system (time point 1 [TP1]). The intrarater and retest reliability
was undertaken 2 months later using the same photographs and
procedure (time point 2 [TP2]). The external validity of the system
was then tested on a sample of 327 individuals. The participants
were again directed to classify the same 30 photographs by type
of STs without referring to the classification document.
Analyses of the data were performed to examine the percentage
level of agreement for the type of STs depicted on the photo-
graphs. Test-retest and intrarater reliability was established us-
ing the Fleiss Jtest.
11
Interrater reliability was tested using the
Cohen Jtest. This test was interpreted as satisfactory or not
satisfactory, with the point of discrimination being 0.70.
12
RESULTS
The ISTAP consensus panel consisted of 12 international health-
care professionals. At TP1 and TP2, the data indicated a sub-
stantial agreement on the classification of the 30 images by ST
type, according to the Landis and Koch interpretation
11,13
(Fleiss J
TP1 = 0.619, TP2 = 0.653). Test-retest or intrarater reliability indi-
cated satisfactory agreement between TP1 and TP2 (Cohen J=
0.877).
Following this step, the tool and photographs were sent to a
study group of 327 participants to include 303 healthcare pro-
fessionals and 24 nonnursing subjects (Table 2). The sample con-
sisted of nurses with the credentials of registered nurse, registered
practical nurse/licensed vocational nurse/licensed practical nurse/
certified nursing assistant, and nonnurses from Canada, the United
States, Brazil, the United Kingdom, and China.
There were only 24 nonnursing subjects in the sample; there-
fore, they were excluded from further analysis. Of the 303 health-
care professionals, complete data were available for 190 subjects
(62.7%). The data indicated a moderate level of agreement on
classification of STs by type (Fleiss J=0.545).
Interrater reliability based on wound care expertise was estab-
lished using the Fleiss Jstatistic. The level of agreement for the
Table 1.
INTERNATIONAL SKIN TEAR ADVISORY PANEL MEMBERS
Sharon Baranoski, MSN, RN, CWCN, APN-CCNS, FAAN, Wound Care Dynamics Inc, Shorewood, Illinois
Karen Campbell, PhD, RN, NP, University of Western Ontario, London, Canada
Dawn Christensen, MHSc(N), RN, CETN(C), KDS Professional Consulting, Ottawa, Ontario, Canada
Karen Edwards, MSS, BSN, RN, CWOCN, University of Alabama at Birmingham
Mary Gloeckner, MS, RN, COCN, CWCN, APN, Ostomy/Wound Specialist, Trinity Regional Health System, Rock Island, Illinois
Samantha Holloway, MSc, RN, Wound Healing Research Unit, Institute for Translation, Innovation, Methodology and Engagement, School of Medicine, Cardiff University,
United Kingdom
Diane Langemo, PhD, RN, FAAN, Langemo & Associates, University of North Dakota, Grand Forks
Kimberly LeBlanc, MN, RN, CETN(C) IIWCC, KDS Professional Consulting, Ottawa, Ontario, Canada
Alicia Madore, MSN, RN, CCNS, WCC, Army Nurse Corps
Mary Regan, PhD, RN, CNS, CWCN, Hollister, LLC, Libertyville, Illinois
Mary Ann Sammon, BSN, CWCN, Enterprise Manager, Wound Care Consult Team, Cleveland Clinic, Ohio
Ann Williams, BSN, RN, BC, CWOCN, Wound/Ostomy Care Coordinator, Reston Hospital Center, Virginia
Figure 1.
ISTAP SKIN TEAR CLASSIFICATION
Table 2.
SAMPLE DEMOGRAPHICS
Subjects n %
RN 259 79.2
RPN/LVN/LPN and CNA 44 13.5
Nonnursing 24 7.3
Total 327 100
Abbreviations: CNA, certified nursing assistant; LPN, licensed practical nurse; LVN,
licensed vocational nurse; RN, registered nurse; RPN, registered practical nurse.
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ISTAP on the 30 test ST photographs was substantial (Fleiss J=
0.653).
12
A moderate level of agreement was demonstrated for
both the RN group and the nonYregistered nurse group (Fleiss J=
0.555 and 0.480, respectively). Only a fair level of agreement was
found for the nonnursing subjects (Fleiss J=0.338)(Table3).
DISCUSSION
The primary objective of the ISTAP was to develop and validate a
widely accepted Skin Tear Classification System and establish a
common language for the documentation of STs. Such devel-
opments are paramount to future research related to the predic-
tion, prevention, assessment, and treatment of these unique, yet
understudied, wounds.This is particularly true as STs can often be
incorrectly diagnosed as pressure ulcers.
The results from the validation study demonstrated substantial
intrarater reliability for the expert panel. Moderate interrater re-
liability was demonstrated for the licensed nurses, and fair for the
nonnursing subjects. The expert panel demonstrated a higher
level of agreement than did the healthcare professional group,
who in turn, demonstrated higher agreement than did the non-
healthcare group. These differences were attributed to the level of
expertise and familiarity with the classification system, although
further investigation of this would be required to explain this
finding.
It is proposed that if individuals were given access to the clas-
sification system as a reference, the levels of agreement would be
even greater. The high level of agreement would appear to be
a testament to the simplicity and ease of use of the classification
system.
At present, the classification system is available and has been
tested only in the English language. Given that the study was
conducted in a variety of countries, the researchers presumed a
fair degree of generalizability. It is acknowledged, however, that
further testing and validation with larger numbers of both health-
care and nonhealthcare professionals across different settings
and countries are required. In addition, translation into a variety of
commonly used languages will facilitate implementation globally.
From this study, it was apparent that there were a number of
other gaps in the literature. Therefore, the ISTAP recommends
that further research be conducted. Examples could include
prevalence studies across different healthcare settings to deter-
mine the true extent of ST prevalence and to firmly establish the
need for the wound care community to focus on these complex
acute wounds. Also, the development of a valid and reliable risk
assessment tool applicable to STs in all healthcare settings is
needed. Studies to determine the best practices for the prevention
and treatment of STs are also warranted. In addition, it would be
helpful to identify unpreventable ST situations as a protective
measure to the healthcare systems.
CONCLUSIONS
The expert panel established the ISTAP Skin Tear Classification
System with the goal of raising the global healthcare commu-
nity’s awareness of STs. It is envisioned that the acceptance and
utilization of a common language and classification system for
STs will facilitate best practices and research in this area. Devel-
opment of an internationally recognized and validated classifica-
tion system for STs is an important first step to facilitate the
development of international guidelines for the prevention, pre-
diction, assessment, and management of STs.
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Table 3.
LEVEL OF AGREEMENT
Fleiss
0
Statistic
11
Strength of Agreement
Beyond Chance
12
Expert ISTAP group 0.653 Substantial
RN 0.555 Moderate
LVN/LPN and CNA 0.480 Moderate
Nonnursing 0.338 Fair
Abbreviations: CNA, certified nursing assistant; ISTAP, International Skin Tear Advisory
Panel; LPN, licensed practical nurse; LVN, licensed vocational nurse; RN, registered nurse.
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