Over wondzorg | Cohesie Wondzorg
Standardising the classification of skin tears: validity and reliability testing of the International Skin Tear Advisory Panel (ISTAP) Classification System in 44 countriesSUMMARYBackground Skin tears are acute wounds that are frequently misdiagnosed and underreported. A standardised and globally adopted skin tear classification system with supporting evidence for diagnostic validity and reliability is required to allow assessment and reporting in a consistent way.Objectives To measure the validity and reliability of the International Skin Tear Advisory Panel (ISTAP) Classification System internationally.Methods A multi-country study was set up to validate the content of the ISTAP Classification System through expert consultation in a two-round Delphi procedure involving 17 experts from 11 countries. An online survey including 24 skin tear photographs was conducted in a convenience sample of 1601 healthcare professionals from 44 countries to measure diagnostic accuracy, agreement, inter-rater reliability, and intra-rater reliability of the instrument.Results A definition for the concept of a “skin flap” in the area of skin tears was developed and added to the initial ISTAP Classification System consisting of three skin tear types. The agreement for differentiating type 1 from type 2 and 3 skin tears was 0.86 (95% CI 0.85-0.86), with a sensitivity of 88% and a specificity of 92%. Overall agreement was 0.79 (95% CI 0.79-0.80). The multi-rater Fleiss Kappa was 0.57 (95% CI 0.57-0.57). The Cohen’s Kappa measuring intra-rater reliability was 0.74 (95% CI 0.73-0.75).Conclusions The ISTAP Classification System is supported by evidence for validity and reliability. The outcome of this study is an important step forward towards a more systematic assessment and reporting of skin tears in clinical practice and research globally.Keywords: Skin tear, Classification, ISTAP, Psychometric evaluation, Validity, Reliability INTRODUCTIONSkin tears are common acute wounds with high potential risk of evolving into complex chronic wounds if not properly managedPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MZUJsYW5jPC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48
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ADDIN EN.CITE.DATA 1-4. The International Skin Tear Advisory Panel (ISTAP) defines skin tears as “traumatic wounds caused by mechanical forces, including removal of adhesives. Severity may vary by depth (not extending through the subcutaneous layer)” ADDIN EN.CITE <EndNote><Cite><Author>LeBlanc</Author><Year>2018</Year><RecNum>8406</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>8406</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1539007334">8406</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>LeBlanc, K., et al.</author></authors></contributors><titles><title>Best practice recommendations for the prevention and management of skin tears in aged skin.</title><secondary-title>Wounds International</secondary-title></titles><periodical><full-title>Wounds International</full-title></periodical><dates><year>2018</year></dates><pub-location>Available to download from </pub-location><urls></urls></record></Cite></EndNote>5. They are reported across all healthcare settings and are predominantly found in the elderly, neonates, and the critically and chronically ill populationsPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MZUJsYW5jPC9BdXRob3I+PFllYXI+MjAxNzwvWWVhcj48
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ADDIN EN.CITE.DATA 5, 8, 9.The prevalence of skin tears varies across countries, healthcare settings and patient populations ADDIN EN.CITE <EndNote><Cite><Author>LeBlanc</Author><Year>2018</Year><RecNum>8406</RecNum><DisplayText><style face="superscript">5, 10</style></DisplayText><record><rec-number>8406</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1539007334">8406</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>LeBlanc, K., et al.</author></authors></contributors><titles><title>Best practice recommendations for the prevention and management of skin tears in aged skin.</title><secondary-title>Wounds International</secondary-title></titles><periodical><full-title>Wounds International</full-title></periodical><dates><year>2018</year></dates><pub-location>Available to download from </pub-location><urls></urls></record></Cite><Cite><Author>Chaplain</Author><Year>2018</Year><RecNum>8412</RecNum><record><rec-number>8412</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1539169390">8412</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Valérie Chaplain</author><author>Chantal Labrecque</author><author>Kevin, Y. Woo</author><author>Kimberly LeBlanc</author></authors></contributors><titles><title>French Canadian translation and the validity and inter-rater reliability of the ISTAP Skin Tear Classification System</title><secondary-title>Journal of Wound Care</secondary-title></titles><periodical><full-title>Journal of Wound Care</full-title></periodical><pages>S15-S20</pages><volume>27</volume><number>Sup9</number><keywords><keyword>classification,International Skin Tear Advisory Panel,skin tears,validation studies</keyword></keywords><dates><year>2018</year></dates><accession-num>30207841</accession-num><urls><related-urls><url>, 10. Studies report skin tear prevalence rates between 3.3-19.8% in acute carePEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NY0VybGVhbjwvQXV0aG9yPjxZZWFyPjIwMDQ8L1llYXI+
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ADDIN EN.CITE.DATA 9, 23, 29-34. The variety in prevalence and incidence rates may in part be attributed to varying patient populations, differences in prevention and management practices, nurses’ knowledge and equipment, but can also be explained by the lack of a uniform method for assessment and documentation ADDIN EN.CITE <EndNote><Cite><Author>LeBlanc</Author><Year>2018</Year><RecNum>8406</RecNum><DisplayText><style face="superscript">5, 35</style></DisplayText><record><rec-number>8406</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1539007334">8406</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>LeBlanc, K., et al.</author></authors></contributors><titles><title>Best practice recommendations for the prevention and management of skin tears in aged skin.</title><secondary-title>Wounds International</secondary-title></titles><periodical><full-title>Wounds International</full-title></periodical><dates><year>2018</year></dates><pub-location>Available to download from </pub-location><urls></urls></record></Cite><Cite><Author>LeBlanc</Author><Year>2014</Year><RecNum>8437</RecNum><record><rec-number>8437</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1541690042">8437</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>LeBlanc, Kimberly</author><author>Baranoski, Sharon</author><author>Holloway, Samantha</author><author>Langemo, Diane</author><author>Regan, Mary</author></authors></contributors><titles><title>A descriptive cross-sectional international study to explore current practices in the assessment, prevention and treatment of skin tears</title><secondary-title>International Wound Journal</secondary-title></titles><periodical><full-title>International Wound Journal</full-title></periodical><pages>424-430</pages><volume>11</volume><number>4</number><dates><year>2014</year></dates><urls><related-urls><url>, 35. A cross-sectional international study including 1127 healthcare professionals from 16 countries revealed significant problems with the assessment, classification and documentation of skin tears ADDIN EN.CITE <EndNote><Cite><Author>LeBlanc</Author><Year>2014</Year><RecNum>8437</RecNum><DisplayText><style face="superscript">35</style></DisplayText><record><rec-number>8437</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1541690042">8437</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>LeBlanc, Kimberly</author><author>Baranoski, Sharon</author><author>Holloway, Samantha</author><author>Langemo, Diane</author><author>Regan, Mary</author></authors></contributors><titles><title>A descriptive cross-sectional international study to explore current practices in the assessment, prevention and treatment of skin tears</title><secondary-title>International Wound Journal</secondary-title></titles><periodical><full-title>International Wound Journal</full-title></periodical><pages>424-430</pages><volume>11</volume><number>4</number><dates><year>2014</year></dates><urls><related-urls><url>. The majority of respondents (70%) reported issues with the assessment and documentation of skin tears in their settings, with an overwhelming majority (90%) preferring a simplified method. Eighty-one percent of respondents reported not using any tool or classification system for the classification of skin tears and 40% admitted to ignoring and not documenting any information about these wounds ADDIN EN.CITE <EndNote><Cite><Author>LeBlanc</Author><Year>2014</Year><RecNum>8437</RecNum><DisplayText><style face="superscript">35</style></DisplayText><record><rec-number>8437</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1541690042">8437</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>LeBlanc, Kimberly</author><author>Baranoski, Sharon</author><author>Holloway, Samantha</author><author>Langemo, Diane</author><author>Regan, Mary</author></authors></contributors><titles><title>A descriptive cross-sectional international study to explore current practices in the assessment, prevention and treatment of skin tears</title><secondary-title>International Wound Journal</secondary-title></titles><periodical><full-title>International Wound Journal</full-title></periodical><pages>424-430</pages><volume>11</volume><number>4</number><dates><year>2014</year></dates><urls><related-urls><url>. In addition, skin tears are often not recognised as unique wounds distinct from other wound types, making them frequently misdiagnosed and underreported ADDIN EN.CITE <EndNote><Cite><Author>LeBlanc</Author><Year>2018</Year><RecNum>8406</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>8406</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1539007334">8406</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>LeBlanc, K., et al.</author></authors></contributors><titles><title>Best practice recommendations for the prevention and management of skin tears in aged skin.</title><secondary-title>Wounds International</secondary-title></titles><periodical><full-title>Wounds International</full-title></periodical><dates><year>2018</year></dates><pub-location>Available to download from </pub-location><urls></urls></record></Cite></EndNote>5.The lack of diagnostic accuracy results in delayed or inappropriate management, causing increased pain and suffering, delayed wound healing, infection, prolonged hospitalisation, and high health care costs, all negatively affecting the quality of carePEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TdHJhenppZXJpLVB1bGlkbzwvQXV0aG9yPjxZZWFyPjIw
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ADDIN EN.CITE.DATA 38, 39. The ISTAP tool classifies skin tears based on the severity of “skin flap” loss, but does not provide a definition of a “skin flap”. In their best practice document, developed in 2018, the ISTAP panel indicated a need for standardised terminology in order to avoid confusion ADDIN EN.CITE <EndNote><Cite><Author>LeBlanc</Author><Year>2018</Year><RecNum>8406</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>8406</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1539007334">8406</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>LeBlanc, K., et al.</author></authors></contributors><titles><title>Best practice recommendations for the prevention and management of skin tears in aged skin.</title><secondary-title>Wounds International</secondary-title></titles><periodical><full-title>Wounds International</full-title></periodical><dates><year>2018</year></dates><pub-location>Available to download from </pub-location><urls></urls></record></Cite></EndNote>5. Since 2013, the ISTAP Classification System has been translated and its psychometric properties were measured in Denmark ADDIN EN.CITE <EndNote><Cite><Author>Skiveren</Author><Year>2015</Year><RecNum>8442</RecNum><DisplayText><style face="superscript">40</style></DisplayText><record><rec-number>8442</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1543588022">8442</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Skiveren, J</author><author>Bermark, S</author><author>LeBlanc, K</author><author>Baranoski, S</author></authors></contributors><titles><title>Danish Translation and validation of the international skin tear advisory panel skin tear classification system</title><secondary-title>Journal of wound care</secondary-title></titles><periodical><full-title>Journal of Wound Care</full-title></periodical><pages>388-392</pages><volume>24</volume><number>8</number><dates><year>2015</year></dates><isbn>0969-0700</isbn><urls></urls></record></Cite></EndNote>40, Sweden ADDIN EN.CITE <EndNote><Cite><Author>K?llman</Author><Year>2018</Year><RecNum>8443</RecNum><DisplayText><style face="superscript">41</style></DisplayText><record><rec-number>8443</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1543588057">8443</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>K?llman, Ulrika</author><author>Kimberly, Le Blanc</author><author>B??th, Carina</author></authors></contributors><titles><title>Swedish translation and validation of the international skin tear advisory panel skin tear classification system</title><secondary-title>International wound journal</secondary-title></titles><periodical><full-title>International Wound Journal</full-title></periodical><dates><year>2018</year></dates><isbn>1742-4801</isbn><urls></urls></record></Cite></EndNote>41, French Canada ADDIN EN.CITE <EndNote><Cite><Author>Chaplain</Author><Year>2018</Year><RecNum>8412</RecNum><DisplayText><style face="superscript">10</style></DisplayText><record><rec-number>8412</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1539169390">8412</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Valérie Chaplain</author><author>Chantal Labrecque</author><author>Kevin, Y. Woo</author><author>Kimberly LeBlanc</author></authors></contributors><titles><title>French Canadian translation and the validity and inter-rater reliability of the ISTAP Skin Tear Classification System</title><secondary-title>Journal of Wound Care</secondary-title></titles><periodical><full-title>Journal of Wound Care</full-title></periodical><pages>S15-S20</pages><volume>27</volume><number>Sup9</number><keywords><keyword>classification,International Skin Tear Advisory Panel,skin tears,validation studies</keyword></keywords><dates><year>2018</year></dates><accession-num>30207841</accession-num><urls><related-urls><url>, and Brazil ADDIN EN.CITE <EndNote><Cite><Author>da Silva</Author><Year>2018</Year><RecNum>8445</RecNum><DisplayText><style face="superscript">42</style></DisplayText><record><rec-number>8445</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1543588136">8445</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>da Silva, Cinthia Viana Bandeira</author><author>Campanili, Ticiane Carolina Gon?alves Faustino</author><author>LeBlanc, Kimberly</author><author>Baranoski, Sharon</author><author>de Gouveia Santos, Vera Lúcia Concei??o</author></authors></contributors><titles><title>Cultural adaptation and content validity of ISTAP Skin Tear Classification for Portuguese in Brazil</title><secondary-title>Revista Estima</secondary-title></titles><periodical><full-title>Revista Estima</full-title></periodical><volume>16</volume><number>1</number><dates><year>2018</year></dates><isbn>2595-7007</isbn><urls></urls></record></Cite></EndNote>42. It is acknowledged that further psychometric testing with larger samples of healthcare professionals across settings and countries is required ADDIN EN.CITE <EndNote><Cite><Author>LeBlanc</Author><Year>2013</Year><RecNum>8441</RecNum><DisplayText><style face="superscript">39</style></DisplayText><record><rec-number>8441</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1543587981">8441</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>LeBlanc, Kimberly</author><author>Baranoski, Sharon</author><author>Holloway, Samantha</author><author>Langemo, Diane</author></authors></contributors><titles><title>Validation of a new classification system for skin tears</title><secondary-title>Advances in skin & wound care</secondary-title></titles><periodical><full-title>Advances in Skin & Wound Care</full-title></periodical><pages>263-265</pages><volume>26</volume><number>6</number><dates><year>2013</year></dates><isbn>1527-7941</isbn><urls></urls></record></Cite></EndNote>39. The aim of this study was to evaluate the validity and reliability of the ISTAP Classification System internationally.METHODSThe study consisted of two phases. Phase 1 was a study to validate the content of the ISTAP Classification System through expert consultation in a two-round Delphi procedure. Phase 2 included the measurement of the psychometric properties of the instrument. Diagnostic accuracy, agreement, inter-rater reliability, and intra-rater reliability were measured.Phase 1. Design and content validation of a definition for the concept of a “skin flap” in skin tearsFollowing the development of the ISTAP best practice document ADDIN EN.CITE <EndNote><Cite><Author>LeBlanc</Author><Year>2018</Year><RecNum>8406</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>8406</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1539007334">8406</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>LeBlanc, K., et al.</author></authors></contributors><titles><title>Best practice recommendations for the prevention and management of skin tears in aged skin.</title><secondary-title>Wounds International</secondary-title></titles><periodical><full-title>Wounds International</full-title></periodical><dates><year>2018</year></dates><pub-location>Available to download from </pub-location><urls></urls></record></Cite></EndNote>5, a definition of a “skin flap” was proposed to be added to the current ISTAP classification tool. A first proposal of a definition was developed by the core team of this study based on a literature review. A two-round Delphi procedure was conducted to collect feedback and to achieve consensus on the proposed definition. The expert panel consisted of 17 international key opinion leaders based in Australia (n=1), Belgium (n=1), Canada (n=3), Chile (n=1), Italy (n=1), Japan (n=1), South Africa (n=1), Switzerland (n=1), the United Arab Emirates (n=1), the United Kingdom (n=2), and the United States of America (n=4). All were executive board members of the International Skin Tear Advisory Panel (ISTAP). In the first Delphi round, the experts were invited to provide comments on the proposed definition. The feedback was summarised and a new proposal was developed. In the second round, the experts were asked for approval and/or additional comments on the revised definition.Phase 2. Psychometric evaluation of the ISTAP Classification SystemThe aim of this phase was to examine diagnostic accuracy, inter-rater reliability, intra-rater reliability and agreement of the ISTAP Classification System. An online survey including 24 photographs of skin tears was developed using the software package LimeSurvey?. A second survey was sent to the participants one week after completion of the first survey. This survey (re-test) included the identical 24 photographs in a different random order to reduce potential bias. No feedback was provided between the test and re-test. Both English language surveys were translated into 15 languages by native speakers with extensive content expertise to allow data collection in 44 countries. Participants in the survey were invited to categorise the photographs using the ISTAP Classification System. Diagnostic accuracy was evaluated by comparing the classifications of the participants with those of three experts in skin integrity research as reference standard (KLB, KVDB & DB). Inter-rater reliability and agreement was measured within the ratings of the participants. Intra-rater reliability and agreement with one week interval between ratings was calculated for all participants who completed both the first and the second survey.ParticipantsData were collected between September and November 2018 in a convenience sample of healthcare professionals in 44 countries. The sample included healthcare professionals within the network of the study team and a selection of major wound care organisations such as the World Council of Enterostomal Therapists (WCET), Nurses Specialized in Wound, Ostomy and Continence Canada (NSWOCC), Wounds Canada, Wounds Australia, Tissue Viability Society (TVS), Wound, Ostomy and Continence Nurses Society (WOCN), Wound Healing Association of Southern Africa (WHASA), Saudi Chapter?of Enterostomal Therapy (SCET), and V&VN Wound Expertise.PhotographsTwenty-four skin tear photographs (obtained with informed consent from patients to be applied for research purposes) were selected and categorised by three experts in skin integrity research (Table 1). The set equally represented the three types of skin tears and included three photographs from patients with a darkly pigmented skin. There was 100% consensus between the raters in categorising the photographs (reference standard). Sample size calculation was performed by the statistical software package R ADDIN EN.CITE <EndNote><Cite><Author>Team</Author><Year>2018</Year><RecNum>8450</RecNum><DisplayText><style face="superscript">43</style></DisplayText><record><rec-number>8450</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1547043063">8450</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>R Core Team</author></authors></contributors><titles><title>R: A language and environment for statistical computing.</title></titles><dates><year>2018</year></dates><pub-location>R Foundation for Statistical Computing, Vienna, Austria.</pub-location><urls><related-urls><url> using the function CI3Cats in the kappaSize package (version 1.2) ADDIN EN.CITE <EndNote><Cite><Author>Rotondi</Author><Year>2012</Year><RecNum>8449</RecNum><DisplayText><style face="superscript">44, 45</style></DisplayText><record><rec-number>8449</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1547042277">8449</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rotondi, Michael A</author><author>Donner, Allan</author></authors></contributors><titles><title>A confidence interval approach to sample size estimation for interobserver agreement studies with multiple raters and outcomes</title><secondary-title>Journal of clinical epidemiology</secondary-title></titles><periodical><full-title>Journal of clinical epidemiology</full-title></periodical><pages>778-784</pages><volume>65</volume><number>7</number><dates><year>2012</year></dates><isbn>0895-4356</isbn><urls></urls></record></Cite><Cite><Author>Rotondi</Author><Year>2018</Year><RecNum>8448</RecNum><record><rec-number>8448</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1547042068">8448</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Rotondi, Michael A</author></authors></contributors><titles><title>Package ‘kappaSize’</title></titles><dates><year>2018</year></dates><urls><related-urls><url>, 45. The confidence interval-based method was used to determine the number of photographs needed to examine inter-rater reliability with three outcome categories. A minimum of 22 photographs was required, based on an anticipated ?-value of 0.65 ADDIN EN.CITE <EndNote><Cite><Author>LeBlanc</Author><Year>2013</Year><RecNum>8441</RecNum><DisplayText><style face="superscript">39</style></DisplayText><record><rec-number>8441</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1543587981">8441</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>LeBlanc, Kimberly</author><author>Baranoski, Sharon</author><author>Holloway, Samantha</author><author>Langemo, Diane</author></authors></contributors><titles><title>Validation of a new classification system for skin tears</title><secondary-title>Advances in skin & wound care</secondary-title></titles><periodical><full-title>Advances in Skin & Wound Care</full-title></periodical><pages>263-265</pages><volume>26</volume><number>6</number><dates><year>2013</year></dates><isbn>1527-7941</isbn><urls></urls></record></Cite></EndNote>39, an expected lower bound for a two-sided 100(1-α)% confidence interval of 0.48, an expected upper confidence limit of 0.8, and the proportions per skin tear type (type 1=0.33, type 2=0.33, type 3= 0.34).Ethical considerationsThis study was performed in accordance with the ethical guidelines of the Declaration of Helsinki and approved by the Ethics Committee of Ghent University Hospital (B670201836271). All participants received written information about the purpose and procedure before the start of the study. Confidentiality and anonymity of the participants were guaranteed. Return of a completed survey was considered as consent to participate.Data analysisDiagnostic accuracy, agreement, inter-rater reliability and intra-rater reliability were analysed. Summary measures of overall and specific agreement were calculated based on the comparison between the participants’ ratings and the reference standard. The summary measures were the estimated mean with 95% confidence interval (CI), the estimated median value with the interquartile range (IQR), and the 2.5th and 97.5th percentile. In order to calculate diagnostic accuracy, three binary measures were considered: type 1 versus type 2 and 3, type 2 versus type 1 and 3, and type 3 versus type 1 and 2 skin tears. Diagnostic accuracy was assessed by summary measures for sensitivity and specificity of each rater to the reference standard.Inter-rater reliability amongst raters was assessed using the multi-rater Fleiss Kappa. Reference standard scores were not included in the analysis. Intra-rater reliability and agreement were examined by comparing the first and second ratings of the same photographs for participants who completed both the first and the second survey. Summary measures of Cohen’s Kappa, overall and specific agreement were calculated for each individual rater.Kappa coefficients criteria by Landis and Koch were applied (<0.00=Poor; 0.00-0.20=Slight; 0.21-0.40=Fair; 0.41-0.60=Moderate; 0.61-0.80=Substantial; 0.81-1.00=Almost perfect) ADDIN EN.CITE <EndNote><Cite><Author>Landis</Author><Year>1977</Year><RecNum>8329</RecNum><DisplayText><style face="superscript">46</style></DisplayText><record><rec-number>8329</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="0">8329</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Landis, J. R.</author><author>Koch, G. G.</author></authors></contributors><titles><title>The measurement of observer agreement for categorical data</title><secondary-title>Biometrics</secondary-title></titles><periodical><full-title>biometrics</full-title></periodical><pages>159-74</pages><volume>33</volume><number>1</number><keywords><keyword>Humans</keyword><keyword>Multiple Sclerosis/*diagnosis</keyword><keyword>*Statistics as Topic</keyword></keywords><dates><year>1977</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0006-341X (Print)
0006-341X (Linking)</isbn><accession-num>843571</accession-num><urls><related-urls><url>. All statistical analyses were performed in R (version 3.5.1) ADDIN EN.CITE <EndNote><Cite><Author>Team</Author><Year>2018</Year><RecNum>8450</RecNum><DisplayText><style face="superscript">43</style></DisplayText><record><rec-number>8450</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1547043063">8450</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>R Core Team</author></authors></contributors><titles><title>R: A language and environment for statistical computing.</title></titles><dates><year>2018</year></dates><pub-location>R Foundation for Statistical Computing, Vienna, Austria.</pub-location><urls><related-urls><url>. The concordance function in the R-library ‘raters’ (version 2.0.1) was used to obtain Fleiss Kappa and 95% CIs, and the kappa2 function in the R-library ‘irr’ (version 0.84.1) for calculating Cohen’s Kappa.RESULTSPhase 1. Design and content validation of a definition for the concept of a “skin flap” in skin tearsThe Delphi process resulted in the following definition of a “skin flap” associated with the condition of a skin tear: “A flap in skin tears is defined as a portion of the skin (epidermis/dermis) that is unintentionally separated (partially or fully) from its original place due to shear, friction, and/or blunt force. This concept is not to be confused with tissue that is intentionally detached from its place of origin for therapeutic use e.g. surgical skin grafting.”. The three categories of the initial ISTAP tool have remained unchanged. The ISTAP Classification System including the newly developed “skin flap” definition is presented in Figure 1. Phase 2. Psychometric evaluation of the ISTAP Classification SystemCharacteristics of the participantsA total of 1601 participants (89.4% female, mean (SD) age: 41.2 (12.2) years) completed the first survey (test) of which 952 (59.5%) completed the second survey (re-test). Table 2 provides an overview of the sample demographics.Diagnostic accuracy and agreementThe diagnostic accuracy and agreement between the ratings of the participants and the reference standard are presented in Table 3. The average overall agreement was 0.79 (95% CI 0.79-0.80). The mean specific agreement ranged from 0.75 (95% CI 0.74-0.75) for type 2 to 0.76 (95% CI 0.76-0.77) for type 3 to 0.86 (95% CI 0.85-0.86) for type 1 skin tears. A higher overall agreement was found in participants who considered themselves as proficient or expert (0.82 (95% CI 0.81-0.83)), participants with a master’s degree (0.81 (95% CI 0.79-0.82)), and participants that were familiar with the use of the ISTAP Classification System (0.82 (95% CI 0.81-0.83)). A mean sensitivity of 88% (95% CI 0.87-0.88) and a mean specificity of 92% (95% CI 0.92-0.93) were found for differentiating type 1 from type 2 and 3 skin tears. Slightly lower sensitivity and specificity rates were observed for differentiating type 2 from type 1 and 3 skin tears, and type 3 from type 1 and 2 skin tears. Inter- and intra-rater reliabilityThe multi-rater Fleiss Kappa for the entire group of participants was 0.57 (95% CI 0.57-0.57; Table 4). Inter-rater reliability was higher in more experienced healthcare professionals. The mean Cohen’s Kappa representing the intra-rater reliability was 0.74 (95% CI 0.73-0.75) and the average overall agreement was 0.83 (95% CI 0.82-0.84; Table 5). Higher mean specific agreement rates were found compared to the first time of assessment, ranging from 0.78 (95% CI 0.77-0.79) for type 2 to 0.83 (95% CI 0.82-0.84) for type 3 to 0.86 (95% CI 0.85-0.87) for type 1 skin tears.DISCUSSIONAlthough skin tears are unique and highly prevalent wounds, they are often under-recognised, misdiagnosed and poorly reported in clinical practice. Best practice includes early and accurate identification, classification, documentation, and the application of an evidence-based treatment protocol ADDIN EN.CITE <EndNote><Cite><Author>LeBlanc</Author><Year>2018</Year><RecNum>8406</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>8406</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1539007334">8406</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>LeBlanc, K., et al.</author></authors></contributors><titles><title>Best practice recommendations for the prevention and management of skin tears in aged skin.</title><secondary-title>Wounds International</secondary-title></titles><periodical><full-title>Wounds International</full-title></periodical><dates><year>2018</year></dates><pub-location>Available to download from </pub-location><urls></urls></record></Cite></EndNote>5. 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ADDIN EN.CITE.DATA 6, 7. This study aimed to evaluate the validity and reliability of the ISTAP Classification System internationally.Content validity of the ISTAP Classification System including the newly developed “skin flap” definition was established by a panel of 17 international experts. After a two-round Delphi process, consensus was achieved about the definition for the concept of a “skin flap” in skin tears. The development of such definition for the area of skin tears is important because this concept may be interpreted differently depending on one’s educational background ADDIN EN.CITE <EndNote><Cite><Author>da Silva</Author><Year>2018</Year><RecNum>8445</RecNum><DisplayText><style face="superscript">42</style></DisplayText><record><rec-number>8445</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1543588136">8445</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>da Silva, Cinthia Viana Bandeira</author><author>Campanili, Ticiane Carolina Gon?alves Faustino</author><author>LeBlanc, Kimberly</author><author>Baranoski, Sharon</author><author>de Gouveia Santos, Vera Lúcia Concei??o</author></authors></contributors><titles><title>Cultural adaptation and content validity of ISTAP Skin Tear Classification for Portuguese in Brazil</title><secondary-title>Revista Estima</secondary-title></titles><periodical><full-title>Revista Estima</full-title></periodical><volume>16</volume><number>1</number><dates><year>2018</year></dates><isbn>2595-7007</isbn><urls></urls></record></Cite></EndNote>42. In the field of reconstructive surgery, for example, a “skin flap” is considered a mass of tissue intentionally detached from its original place to be used for grafting for wound repair and organ reconstruction ADDIN EN.CITE <EndNote><Cite><Author>Sun</Author><Year>2017</Year><RecNum>8453</RecNum><DisplayText><style face="superscript">47, 48</style></DisplayText><record><rec-number>8453</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1553182264">8453</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sun, Qiushuo</author><author>He, Yuezhi</author><author>Liu, Kai</author><author>Fan, Shuting</author><author>Parrott, Edward PJ</author><author>Pickwell-MacPherson, Emma</author></authors></contributors><titles><title>Recent advances in terahertz technology for biomedical applications</title><secondary-title>Quantitative imaging in medicine and surgery</secondary-title></titles><periodical><full-title>Quantitative imaging in medicine and surgery</full-title></periodical><pages>345</pages><volume>7</volume><number>3</number><dates><year>2017</year></dates><urls></urls></record></Cite><Cite><Author>Chai</Author><Year>2019</Year><RecNum>8454</RecNum><record><rec-number>8454</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1553182354">8454</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Chai, Jun</author><author>Ge, Jun</author><author>Zou, Jun</author></authors></contributors><titles><title>Effect of Autologous Platelet-Rich Plasma Gel on Skin Flap Survival</title><secondary-title>Medical Science Monitor</secondary-title></titles><periodical><full-title>Medical Science Monitor</full-title></periodical><pages>1611-1620</pages><volume>25</volume><dates><year>2019</year></dates><isbn>1234-1010</isbn><urls></urls></record></Cite></EndNote>47, 48. A clear, internationally accepted definition of a “skin flap” associated with the condition of a skin tear should help to eliminate confusion and to facilitate best practice ADDIN EN.CITE <EndNote><Cite><Author>LeBlanc</Author><Year>2018</Year><RecNum>8406</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>8406</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1539007334">8406</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>LeBlanc, K., et al.</author></authors></contributors><titles><title>Best practice recommendations for the prevention and management of skin tears in aged skin.</title><secondary-title>Wounds International</secondary-title></titles><periodical><full-title>Wounds International</full-title></periodical><dates><year>2018</year></dates><pub-location>Available to download from </pub-location><urls></urls></record></Cite></EndNote>5.In this study, psychometric properties of the ISTAP Classification System were examined in a sample of 1601 healthcare professionals from 44 countries. The results indicate a high level of agreement and diagnostic accuracy for differentiating between the three types of skin tears when healthcare professionals apply the ISTAP tool on presented photographs. Differences in classifications were primarily limited to distinguishing between type 2 and type 3 skin tears, which is similar to the findings of K?llman et al. (2018) ADDIN EN.CITE <EndNote><Cite><Author>K?llman</Author><Year>2018</Year><RecNum>8443</RecNum><DisplayText><style face="superscript">41</style></DisplayText><record><rec-number>8443</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1543588057">8443</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>K?llman, Ulrika</author><author>Kimberly, Le Blanc</author><author>B??th, Carina</author></authors></contributors><titles><title>Swedish translation and validation of the international skin tear advisory panel skin tear classification system</title><secondary-title>International wound journal</secondary-title></titles><periodical><full-title>International Wound Journal</full-title></periodical><dates><year>2018</year></dates><isbn>1742-4801</isbn><urls></urls></record></Cite></EndNote>41. The high level of agreement may reflect the ease of use of the tool ADDIN EN.CITE <EndNote><Cite><Author>LeBlanc</Author><Year>2013</Year><RecNum>8441</RecNum><DisplayText><style face="superscript">39</style></DisplayText><record><rec-number>8441</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1543587981">8441</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>LeBlanc, Kimberly</author><author>Baranoski, Sharon</author><author>Holloway, Samantha</author><author>Langemo, Diane</author></authors></contributors><titles><title>Validation of a new classification system for skin tears</title><secondary-title>Advances in skin & wound care</secondary-title></titles><periodical><full-title>Advances in Skin & Wound Care</full-title></periodical><pages>263-265</pages><volume>26</volume><number>6</number><dates><year>2013</year></dates><isbn>1527-7941</isbn><urls></urls></record></Cite></EndNote>39. 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ADDIN EN.CITE.DATA 5, 38. Skin assessment in clinical practice, video recordings, or the exclusive use of photographs in which the skin flap, if viable, has been re-approximated could possibly offer a better alternative.In general, we found higher reliability and agreement rates in more experienced and higher educated healthcare professionals. As skin tears have a complex aetiology, extensive knowledge and experience are required to correctly identify and classify these wounds ADDIN EN.CITE <EndNote><Cite><Author>LeBlanc</Author><Year>2018</Year><RecNum>8406</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>8406</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1539007334">8406</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>LeBlanc, K., et al.</author></authors></contributors><titles><title>Best practice recommendations for the prevention and management of skin tears in aged skin.</title><secondary-title>Wounds International</secondary-title></titles><periodical><full-title>Wounds International</full-title></periodical><dates><year>2018</year></dates><pub-location>Available to download from </pub-location><urls></urls></record></Cite></EndNote>5. Sufficient and adequate education and training of healthcare professionals may enhance the reliability of skin tear assessment. In 2006, a randomised controlled trial including 1217 nurses was conducted to assess the effectiveness of a training program on pressure ulcer classification skills ADDIN EN.CITE <EndNote><Cite><Author>Beeckman</Author><Year>2010</Year><RecNum>8315</RecNum><DisplayText><style face="superscript">49</style></DisplayText><record><rec-number>8315</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="0">8315</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Beeckman, D.</author><author>Schoonhoven, L.</author><author>Fletcher, J.</author><author>Furtado, K.</author><author>Heyman, H.</author><author>Paquay, L.</author><author>De Bacquer, D.</author><author>Defloor, T.</author></authors></contributors><auth-address>Department of Public Health, Ghent University, Gent, Belgium. dimitri.beeckman@ugent.be</auth-address><titles><title>Pressure ulcers and incontinence-associated dermatitis: effectiveness of the Pressure Ulcer Classification education tool on classification by nurses</title><secondary-title>Qual Saf Health Care</secondary-title><alt-title>Quality & safety in health care</alt-title></titles><periodical><full-title>Qual Saf Health Care</full-title></periodical><pages>e3</pages><volume>19</volume><number>5</number><edition>2010/07/31</edition><keywords><keyword>Adult</keyword><keyword>Dermatitis/*classification/etiology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Nursing Staff/*education</keyword><keyword>Pressure Ulcer/*classification</keyword><keyword>Urinary Incontinence/*complications</keyword><keyword>Young Adult</keyword></keywords><dates><year>2010</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>1475-3898</isbn><accession-num>20671078</accession-num><urls><related-urls><url>. The results of this study revealed a significant improvement in pressure ulcer identification and classification skills after attending the training program based on the Pressure Ulcer Classification (PUCLAS) education tool. In line with the PUCLAS tool, the development of an (e-learning) education tool for skin tear identification and classification that can be easily implemented by educators and healthcare organisations might facilitate learning and improve skills. Further research is needed to evaluate whether, and to what extent, education and training of (future) healthcare professionals would improve skin tear assessment and classification skills.In the field of pressure ulcers, the National Pressure Ulcer Advisory Panel (NPUAP) ADDIN EN.CITE <EndNote><Cite><Author>Edsberg</Author><Year>2016</Year><RecNum>8463</RecNum><DisplayText><style face="superscript">50</style></DisplayText><record><rec-number>8463</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1556273627">8463</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Edsberg, Laura E</author><author>Black, Joyce M</author><author>Goldberg, Margaret</author><author>McNichol, Laurie</author><author>Moore, Lynn</author><author>Sieggreen, Mary</author></authors></contributors><titles><title>Revised National Pressure Ulcer Advisory Panel pressure injury staging system: revised pressure injury staging system</title><secondary-title>Journal of Wound, Ostomy, and Continence Nursing</secondary-title></titles><periodical><full-title>Journal of Wound, Ostomy, and Continence Nursing</full-title></periodical><pages>585</pages><volume>43</volume><number>6</number><dates><year>2016</year></dates><urls></urls></record></Cite></EndNote>50 and European Pressure Ulcer Advisory Panel (EPUAP) ADDIN EN.CITE <EndNote><Cite><Author>EPUAP.</Author><Year>2002</Year><RecNum>8457</RecNum><DisplayText><style face="superscript">51</style></DisplayText><record><rec-number>8457</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1553768113">8457</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>EPUAP.</author></authors></contributors><titles><title>Guide to Pressure Ulcer Grading</title><secondary-title>EPUAP Review</secondary-title></titles><periodical><full-title>EPUAP Review</full-title></periodical><pages>75</pages><volume>3</volume><dates><year>2002</year></dates><urls></urls></record></Cite></EndNote>51 classification systems are widely used for the classification and documentation of pressure ulcersPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CZWVja21hbjwvQXV0aG9yPjxZZWFyPjIwMDc8L1llYXI+
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ADDIN EN.CITE.DATA 52, 53. To support the assessment of incontinence‐associated dermatitis (IAD), the Ghent Global IAD Categorization Tool (GLOBIAD) has been developed and globally validated in 2017 ADDIN EN.CITE <EndNote><Cite><Author>Beeckman</Author><Year>2018</Year><RecNum>8456</RecNum><DisplayText><style face="superscript">54</style></DisplayText><record><rec-number>8456</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1553767333">8456</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Beeckman, Dimitri</author><author>Van den Bussche, Karen</author><author>Alves, Paulo</author><author>Arnold Long, Mary C</author><author>Beele, Hilde</author><author>Ciprandi, Guido</author><author>Coyer, Fiona</author><author>de Groot, Tonny</author><author>De Meyer, Dorien</author><author>Deschepper, Ellen</author></authors></contributors><titles><title>Towards an international language for incontinence‐associated dermatitis (IAD): design and evaluation of psychometric properties of the Ghent Global IAD Categorization Tool (GLOBIAD) in 30 countries</title><secondary-title>British Journal of Dermatology</secondary-title></titles><periodical><full-title>British Journal of Dermatology</full-title></periodical><pages>1331-1340</pages><volume>178</volume><number>6</number><dates><year>2018</year></dates><isbn>0007-0963</isbn><urls></urls></record></Cite></EndNote>54. In line with the GLOBIAD, NPUAP and EPUAP classification systems, the systematic assessment and reporting of skin tears using a valid and reliable international classification tool is recommended ADDIN EN.CITE <EndNote><Cite><Author>LeBlanc</Author><Year>2018</Year><RecNum>8406</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>8406</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1539007334">8406</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>LeBlanc, K., et al.</author></authors></contributors><titles><title>Best practice recommendations for the prevention and management of skin tears in aged skin.</title><secondary-title>Wounds International</secondary-title></titles><periodical><full-title>Wounds International</full-title></periodical><dates><year>2018</year></dates><pub-location>Available to download from </pub-location><urls></urls></record></Cite></EndNote>5. The results of this study show that skin tear photographs can be assessed in a valid and reliable way based on the ISTAP Classification System. In the context of our study, the ISTAP Classification System including the “skin flap” definition has been translated into 15 languages and disseminated across 44 countries, encouraging global awareness and implementation ADDIN EN.CITE <EndNote><Cite><Author>LeBlanc</Author><Year>2013</Year><RecNum>8441</RecNum><DisplayText><style face="superscript">39</style></DisplayText><record><rec-number>8441</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1543587981">8441</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>LeBlanc, Kimberly</author><author>Baranoski, Sharon</author><author>Holloway, Samantha</author><author>Langemo, Diane</author></authors></contributors><titles><title>Validation of a new classification system for skin tears</title><secondary-title>Advances in skin & wound care</secondary-title></titles><periodical><full-title>Advances in Skin & Wound Care</full-title></periodical><pages>263-265</pages><volume>26</volume><number>6</number><dates><year>2013</year></dates><isbn>1527-7941</isbn><urls></urls></record></Cite></EndNote>39. It should be considered to integrate the ISTAP tool into the (electronic) medical record so that consistent documentation is guaranteed and more accurate skin tear prevalence and incidence data are obtained. Furthermore, the common use of the ISTAP Classification System to support skin tear assessment and documentation will facilitate and standardise communication, benchmarking, clinical audits and researchPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MZUJsYW5jPC9BdXRob3I+PFllYXI+MjAxNzwvWWVhcj48
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ADDIN EN.CITE.DATA 6, 7, 16. Strengths and limitationsOur study was a global validation study including a large number of international experts and healthcare professionals with different backgrounds across a variety of settings and countries. This increases the generalisability of our findings and may contribute to global awareness and implementation of the ISTAP Classification System. A main limitation of this study might be the use of photographs which only provide a static, two-dimensional image of the wound. Assessment in clinical practice might allow a more holistic evaluation involving additional factors such as the cause of the wound, accurate flap visualisation, partial/full-thickness, health status, wound history, and dependency for daily living activities ADDIN EN.CITE <EndNote><Cite><Author>LeBlanc</Author><Year>2018</Year><RecNum>8406</RecNum><DisplayText><style face="superscript">5, 40</style></DisplayText><record><rec-number>8406</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1539007334">8406</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>LeBlanc, K., et al.</author></authors></contributors><titles><title>Best practice recommendations for the prevention and management of skin tears in aged skin.</title><secondary-title>Wounds International</secondary-title></titles><periodical><full-title>Wounds International</full-title></periodical><dates><year>2018</year></dates><pub-location>Available to download from </pub-location><urls></urls></record></Cite><Cite><Author>Skiveren</Author><Year>2015</Year><RecNum>8442</RecNum><record><rec-number>8442</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1543588022">8442</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Skiveren, J</author><author>Bermark, S</author><author>LeBlanc, K</author><author>Baranoski, S</author></authors></contributors><titles><title>Danish Translation and validation of the international skin tear advisory panel skin tear classification system</title><secondary-title>Journal of wound care</secondary-title></titles><periodical><full-title>Journal of Wound Care</full-title></periodical><pages>388-392</pages><volume>24</volume><number>8</number><dates><year>2015</year></dates><isbn>0969-0700</isbn><urls></urls></record></Cite></EndNote>5, 40. Whether skin tear assessment in clinical practice is more accurate than with photographs is yet to be established. Furthermore, we only included photographs of skin tears, but it is well known that skin tears are frequently incorrectly diagnosed as other lesions, such as pressure ulcersPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MZUJsYW5jPC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48
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ADDIN EN.CITE.DATA 7, 39. Therefore, it would be recommended to also include photographs of other wound types in future validation studies to evaluate whether the differential diagnosis between skin tears and other types of lesions can be made. Another limitation might be that there were only three photographs of darkly pigmented skin included, which may limit the applicability of our findings to all skin phototypes.CONCLUSIONSThe global validation of the ISTAP Classification System is a major step forward towards a more systematic assessment and reporting of skin tears in clinical practice and research. The ISTAP Classification System seems to be a valid, reliable, and easy-to-use tool for classifying skin tears according to their severity level. The ISTAP tool is available in 15 languages, which may enhance global implementation. ACKNOWLEDGEMENTSThe authors would like to thank the international experts for their contributions in the content validation, translation and dissemination of the ISTAP Classification System, the wound care organisations for disseminating the survey, and all healthcare professionals who participated in this study.REFERENCES ADDIN EN.REFLIST 1.LeBlanc K, Christensen D, Cook J et al. Prevalence of Skin Tears in a Long-term Care Facility. Journal of Wound Ostomy & Continence Nursing 2013; 40:580-584.2.Skiveren J, Bermark S, LeBlanc K, Baranoski S. Danish translation and validation of the International Skin Tear Advisory Panel Skin Tear Classification System. Journal of Wound Care 2015; 24:388-392.3.Bermark S, Wahlers B, Gerber AL et al. Prevalence of skin tears in the extremities in inpatients at a hospital in Denmark. International Wound Journal 2018; 15:212-217.4.LeBlanc K, Baranoski S. Skin tears: Best practices for care and prevention. Nursing2018 2014; 44:36-46.5.LeBlanc K et al. 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Qual Saf Health Care 2010; 19:e3.50.Edsberg LE, Black JM, Goldberg M et al. Revised National Pressure Ulcer Advisory Panel pressure injury staging system: revised pressure injury staging system. Journal of Wound, Ostomy, and Continence Nursing 2016; 43:585.51.EPUAP. Guide to Pressure Ulcer Grading. EPUAP Review 2002; 3:75.52.Beeckman D, Schoonhoven L, Fletcher J et al. EPUAP classification system for pressure ulcers: European reliability study. J Adv Nurs 2007; 60:682-691.53.Defloor T, Schoonhoven L, Katrien V et al. Reliability of the European pressure ulcer advisory panel classification system. Journal of advanced nursing 2006; 54:189-198.54.Beeckman D, Van den Bussche K, Alves P et al. Towards an international language for incontinence‐associated dermatitis (IAD): design and evaluation of psychometric properties of the Ghent Global IAD Categorization Tool (GLOBIAD) in 30 countries. British Journal of Dermatology 2018; 178:1331-1340.55.Benner P. From novice to expert. AJN The American Journal of Nursing 1982; 82:402-407.FIGURE LEGENDSFigure 1. The International Skin Tear Advisory Panel (ISTAP) Classification SystemTable 1. Classification of the photographs by three expertsTypeNumber of photographs aNon-pigmented skinPigmented skinTotal1No skin/flap loss8082Partial skin/flap loss5383Total skin/flap loss808Total213 24a The set of 24 photographs used in both survey 1 (test) and survey 2 (re-test) was identical.Table 2. Demographics of the participants?Test?Re-test?n1601952n%n%GenderFemale143289.485389.6Age Mean (SD) in years 41.2 (12.2) 42.1 (11.7)Age< 30 years36122.517718.630 - 39 years38724.224425.640 - 49 years38323.923825.0≥ 50 years47029.429330.8RoleStudent Nurse392.4131.4Nurse assistant261.6121.3Nurse74546.541643.7Head nurse613.8444.6Nurse specialist64440.240442.4Educator452.8343.6Researcher211.3151.6Other161.0101.1Missing40.240.4EducationUndergraduate41726.024125.3Bachelor's degree63339.535237.0Master's degree47529.731032.6Doctoral degree734.6495.1Other / unknown30.200.0Work experience in health care< 5 years30619.114715.45 - 10 years28717.917118.011 - 20 years36022.523925.1> 20 years64840.539541.5Current work settingLocal hospital54634.132333.9Teaching / university hospital42526.525126.4Magnet hospital553.4212.2Nursing home1167.2687.1Community care24315.216217.0Education935.8596.2Clinical research201.2151.6Industry / commercial90.650.5No work / student412.6242.5Other503.1242.5Missing30.200.0Expertise in skin tears aNovice21913.711211.8Advanced Beginner26116.313814.5Competent38924.322924.1Proficient40025.025226.5Expert33220.722123.2Wound care module bCompleted86954.354056.7Observation of skin tears in practice cNone21613.512713.3< 5 times a week98961.860263.25 -10 times a week 32220.118319.2> 10 times a week744.6404.2Experience ISTAP tool dNo previous experience114371.465068.3Language eArabic80.530.3Chinese1469.1727.6Czech1127.0616.4Danish181.1121.3Dutch29518.421622.7English38123.819520.5French704.4555.8German1096.8626.5Hebrew623.9353.7Italian312.0151.6Japanese543.4464.8Portuguese472.9373.9Spanish704.4454.7Swedish563.5353.7Turkish1418.8636.6Country of workAustralia825.1505.3Austria50.340.4Belgium17510.912813.4Botswana20.110.1Brazil30.210.1Canada1227.6899.3Chile694.3454.7China1489.2747.8Colombia10.100.0Costa Rica20.100.0Cyprus10.110.1Czech Republic1056.6586.1Denmark191.2121.3Germany1056.6586.1India10.100.0Indonesia30.210.1Iran20.100.0Ireland20.120.2Israel623.9353.7Italy311.9151.6Japan543.4464.8Jersey10.100.0Kenya20.110.1Malaysia10.100.0Malta30.220.2Mauritius10.100.0Namibia20.110.1the Netherlands1257.8899.3Norway10.110.1Philippines30.230.3Portugal503.1394.1Saudi Arabia10.110.1Singapore20.110.1Slovakia60.430.3South Africa563.5242.5Sri Lanka10.100.0Sweden563.5353.7Switzerland20.110.1Taiwan20.120.2Thailand10.100.0Turkey1418.8636.6United Arab Emirates90.630.3United Kingdom332.1101.1United States of America1086.7535.6a Expertise in relation to the assessment and management of skin tears (based on the levels of proficiency defined by Patricia Benner ADDIN EN.CITE <EndNote><Cite><Author>Benner</Author><Year>1982</Year><RecNum>8462</RecNum><DisplayText><style face="superscript">55</style></DisplayText><record><rec-number>8462</rec-number><foreign-keys><key app="EN" db-id="pt9ettsthpdrpxewd29xdvzx9ezaprezd0ff" timestamp="1556269776">8462</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Benner, Patricia</author></authors></contributors><titles><title>From novice to expert</title><secondary-title>AJN The American Journal of Nursing</secondary-title></titles><periodical><full-title>AJN The American Journal of Nursing</full-title></periodical><pages>402-407</pages><volume>82</volume><number>3</number><dates><year>1982</year></dates><isbn>0002-936X</isbn><urls></urls></record></Cite></EndNote>55). b Completion of a recognised wound care module. c Estimated number of observed skin tears in practice (average a week). d Previous experience with using the ISTAP Classification System. e Languages in which the ISTAP Classification System and the online survey were translated.Table 3. Diagnostic accuracy and agreement with reference standard – 1601 ratersmean (95% CI)median (IQR)2.5th and 97.5th percentilePo a0.79 (0.79-0.80)0.83 (0.75-0.88)0.42-0.96Ptype 1 b0.86 (0.85-0.86)0.89 (0.80-0.94)0.43-1.00Ptype 2 b0.75 (0.74-0.75)0.78 (0.67-0.88)0.31-0.94Ptype 3 b0.76 (0.76-0.77)0.80 (0.71-0.88)0.32-1.00Type 1 vs 2+3Sensitivity0.88 (0.87-0.88)0.88 (0.88-1.00)0.38-1.00Specificity0.92 (0.92-0.93)0.94 (0.88-1.00)0.69-1.00Type 2 vs 1+3Sensitivity0.77 (0.76-0.77)0.75 (0.62-0.88)0.25-1.00Specificity0.86 (0.86-0.87)0.88 (0.81-0.94)0.56-1.00Type 3 vs 1+2Sensitivity0.74 (0.73-0.75)0.75 (0.62-0.88)0.25-1.00Specificity0.91 (0.90-0.91)0.94 (0.88-1.00)0.62-1.00Type 1, no skin/flap loss; Type 2, partial skin/flap loss; Type 3, total skin/flap loss; 95% CI, 95% confidence interval; IQR, interquartile range. a Overall proportion of agreement. b Proportion of specific agreement.Table 4. Inter-rater reliability – 1601 raters? (95% CI)Total sample (n=1601)0.57 (0.57-0.57)Expertise in skin tearsNovice (n=219)0.43 (0.42-0.43)Advanced Beginner (n=261)0.56 (0.56-0.56)Competent (n=389)0.57 (0.57-0.57)Proficient (n=400)0.62 (0.62-0.62)Expert (n=332)0.64 (0.64-0.64)EducationUndergraduate (n=417)0.55 (0.55-0.55)Bachelor’s degree (n=633)0.58 (0.57-0.58)Master’s degree (n=475)0.59 (0.59-0.59)Doctoral degree (n=73)0.53 (0.52-0.53)Experience ISTAP toolPrevious experience (n=458)0.64 (0.64-0.64)No previous experience (n=1143)0.55 (0.55-0.55)?, Fleiss Kappa coefficient; 95% CI, 95% confidence interval.Table 5. Intra-rater reliability and agreement – 952 ratersmean (95% CI)median (IQR)2.5th and 97.5th percentile? a0.74 (0.73-0.75)0.75 (0.68-0.87)0.31-0.94Po b0.83 (0.82-0.84)0.83 (0.79-0.92)0.54-0.96Ptype 1 c0.86 (0.85-0.87)0.89 (0.82-0.94)0.54-1.00Ptype 2 c0.78 (0.77-0.79)0.82 (0.71-0.89)0.39-0.95Ptype 3 c0.83 (0.82-0.84)0.86 (0.78-0.92)0.50-1.00Type 1, no skin/flap loss; Type 2, partial skin/flap loss; Type 3, total skin/flap loss; 95% CI, 95% confidence interval; IQR, interquartile range. a ?, Cohen’s Kappa coefficient. b Overall proportion of agreement. c Proportion of specific agreement. ................
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