Why does the wound physician want to change an unstageable wound to a stage 3?

An unstageable pressure injury is defined as a wound that is covered by a surface layer of either slough or eschar that obscures the depth of the wound, making accurate staging impossible. In my review of the wound programs of many post-acute and long-term care facilities, I often find that the “unstageable” staging designation remains in place for many weeks after admission.

In the Minimum Data Set (MDS) evaluation, the designation of stages 2, 3 or 4 pressure injuries contribute to the wound-related Quality Measures (QMs) for the facility. However, the unstageable designation doesn’t contribute to the QMs. There may be a hesitation to change the wound stage from unstageable to the correct stage wound because of a negative effect on the facility’s wound QM measures.

With few exceptions (such as an intact stable eschar over the heel), the goal of care of an unstageable wound is to remove the devitalized tissue by mechanical or enzymatic debridement to accelerate healing. Once the base of the wound can be assessed and the depth of the wound can be measured, the wound staging should be updated. 

This is not the same as “backstaging” a wound. Updating the correct staging of a pressure injury when adequate information is known is appropriate. Many facilities seem reluctant to appropriately stage wounds when the depth of the wound is known. I fear that some facilities may retain the “unstageable” designation because this doesn’t count adversely toward their QMs.

We should always practice and operate with honesty, integrity and transparency, particularly with regard to wound care. Knowingly misrepresenting the staging of wounds is a slippery slope that is to be avoided.

Mary P. Evans, M.D., CMD, CWSP, Certified Medical Director and Certified Wound Specialist Physician