Disagreement with medical director over wound staging

[savoytruffle, BSN, RN]

Fair warning: I'm a bit frustrated. I am a certified RAC-CT for the MDS. I am a nurse manager with six years LTC exp. I asked the MD to take a look at a coccyx wound that had deteriorated since I last saw it on rounds. He classified it as unstageable. I saw a stage III with 25% red granulation tissue and 75% yellow slough. I questioned why he thought it was unstageable and he said "any appearance of slough in the wound makes the wound unstageable because the wound bed cannot be visualized". So we go from a stage II right to a US because of any slough? He would not listen to me and I am planning on emailing him the MDS manual sections and the NPUAP guidelines for staging. The frustrating part is they the other RNs (namely my DON and ADON) side with him because they said "he is the doctor and we have to go with what he tells us". I'm not even making that up. I felt like I was in a fifties TV show. Unless the guidelines have changed since I last read them, I know I'm right. Has anyone ever heard of calling a wound unstageable because of any visible slough?

[arkool2004]

Found this and thought it would help...

Used with permission NPUAP:

"Full thickness tissue loss in which the base of the ulcer is completely covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed"

"Further Description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth and stage cannot be determined. However, it will be either a Stage III or IV".

[savoytruffle, BSN, RN]

So what parameters does one use to determine that enough of the wound bed is visible enough to stage the wound? Is it subjective?

[arkool2004]

It is my understanding that there has been a change from staging them to just identifying them as partial thickness, full thickness etc. but not necessarily staging

[savoytruffle, BSN, RN]

Where is that information available? NPUAP still has staging guidelines on their website. If I'm doing this wrong I need to correct myself ASAP.

[RainRN1, ASN, RN]

I stage the way the RAI manual says to. I do not go by any other standard. I am also a RAC-CT have been doing MDS since 1998. If you go by too many things you will get confused.

[BSNbeauty, BSN, RN]

Staging wounds can be very subjective. I've disagreed with other nurses and docs when staging as will. I can see why the doc says it is unstageable. I was always taught that if there is any slough in the wound bed ( 75 percent is alot) then it is unstageable.

[Nascar nurse, ASN, RN]

Staging wounds can be very subjective. I've disagreed with other nurses and docs when staging as will. I can see why the doc says it is unstageable. I was always taught that if there is any slough in the wound bed ( 75 percent is alot) then it is unstageable.

agreed - I would have made it unstagable as well. Some LTC facilities will instruct floor nurses not to stage wounds but someone in house IS staging those wounds because they have to be staged to validate the MDS.

[savoytruffle, BSN, RN]

After some reading and discussion i have decided to change the way I am staging. The wound in question is how called unstagable. I also warned my DON that I may be calling more present on admission ulcers this with presence of slough. If called a three, and we clean it out and find a pin hole tract underneath- we now own a deteriorated wound. If I call it unstagable and the same thing happens, I believe it can still be classified as present on admission and not facility acquired. Tricky things.