Accurate tissue identification is one of the most important skills in wound assessment. In this episode, Jeanine Maguire, PhD, MPT, CWS, explains granulation tissue, slough, eschar, and other wound bed characteristics to improve treatment decisions and patient outcomes.
Key Takeaways:
1. Tissue identification drives treatment decisions.
Accurately recognizing granulation tissue, slough, and eschar helps clinicians determine healing status, select appropriate interventions, and monitor progress over time.
2. Wound imaging can improve assessment accuracy.
Consistent photographic documentation helps clinicians compare wounds across transitions of care, support documentation, and reduce discrepancies in tissue identification.
3. The wound bed is only part of the story.
Patient history, anatomy, healing phase, and previous assessments all provide critical context for making accurate wound care decisions and avoiding misdiagnosis.
Transcript
Please note: This content is a direct transcript, capturing the authentic conversation without edits. Some language may reflect the flow of live discussion rather than polished text.
Catherine Milne:
Hello and welcome to Wound Conversations, the podcast where we share actionable insights from leaders in wound healing. I'm Cathy Milne and today we're tackling a topic that every wound care clinician encounters, but not always with complete confidence, tissue types and how to accurately identify what you're seeing in the wound bed. Because let's be honest, terms like slough and eschar, granulation, biofilm, they're easy to define but much harder to interpret consistently in real world practice and those interpretations directly impact the decisions we make. So today we're going to break this down into a practical, clinically meaningful way. I'm joined again by Dr. Jeanine Maguire, a physical therapist and certified wound specialist with extensive experience in clinical care, research, and education related to wound healing. She is also the current president of the Post Acute Wound and Skin Integrity Council, also known as PAWSIC. She has contributed to wound care education through WoundCon and Wound Source.
So Jeanine, welcome back. It's great to have you with us again.
Jeanine Maguire:
Thank you, Cathy. So happy to be here.
Catherine Milne:
Wound Conversations is brought to you by WoundSource, the trusted resource for wound care professionals and WoundCon, your connection to global virtual education and wound management. So let's get started. Listen today and apply tomorrow. Janine, since you've worked across so many areas of wound care, I'd love to ask, and when it comes to wound assessment, do you have an impactful experience to share where focusing on the wound bed or the tissue type really impacted that patient's life or that outcome? Or did it make you a better clinician?
Jeanine Maguire:
That's a really hard question.
Catherine Milne:
I always go back and think of the things I look at my regrets. Gee, I wish I knew. So one of my first regrets was I was managing a guy with a leg wound and I was really early on, like my first year in wound care. And after about three months I said, "It's not healing." And so I sent him to my mentor. It was a basal cell, but I was devastated.
Jeanine Maguire:
That's a sad story and that's helpful for me to think about. So a couple things. So I've been in wound care for more than 30 years and I recall when I first was in practice as a physical therapist, many PTs got our entry into wound care because we were the whirlpool people, the hydro tanks. And so my job as a PTA originally was to scrub up and I scrubbed all the tanks down pre- and post-tank dives. And we put everybody with every wound type in the whirlpool. It didn't matter what it was. I don't even think we knew what they were. They were just open wounds. And one of the learnings from that was that granulation tissue didn't do so good in there.
So the wounds that had more dead tissue, it was easier to debride after the tanks, but the wounds with more granulation, it seemed that they were macerated. It seemed that caused more discomfort for the patient and so on. So early on, starting to recognize that tissue types matter. The second story is probably a little more impactful and it was similar to your experience where in one of the nursing homes that I had oversight of, one of my wound specialists was called to see this patient, a young gentleman, paraplegic, I believe, and he was in high end fluidized bed surface and he developed what they believed was a pressure ulcer at that point in time before pressure injury nomenclature change on his low back. And when she went to evaluate him, she evaluated him holistically. There was nothing that changed in his medical, his nutrition, his mobility.
He was turned and repositioned. He was on this high end bed surface and in the chair that area of wound and the tissues didn't touch anything. And then she learned by doing a deeper dive with his family. When he was a young man, he suffered a burn. So similar to your story, she then realized we need a biopsy and it was a Marjolen's ulcer. And so just having more information about the patient's story is what got him the right diagnosis.
Catherine Milne:
So a lot of times we don't see that long-term history in these electronic medical records and these transitional papers. I mean, when I get a patient, sometimes the discharge summary from the acute care facility is 50 pages long and who's got time for that? I mean, we should have time for that, but there has a lot of redundant information. But when you go, and again, I think you made the great point about the assessment of the holistic assessment of the patient.
Sometimes the patient can't remember something
Catherine Milne:
Or they don't want to share it, but a family member or even calling the previous place where they were at-really can help you make the right tissue type diagnosis.
Jeanine Maguire:
Absolutely. It is very difficult. We certainly have issues with transitions of care all levels. It's an area that I'm hoping in the near future we're going to get our arms around, but you're right. Anytime that patient transitions, there's a lot lost in that transition.
Catherine Milne:
So do you see that the tissue type during transitions of care - the tissue type that was described at place A is different when they arrive at place B?
Jeanine Maguire:
So often. So let's say place A, let's pretend it's a hospital and let's pretend they say it's a hundred percent granulated, 100% beautiful red healing tissue.
Catherine Milne:
Because that's our definition of granulation tissue.
Jeanine Maguire:
That's our definition, right? They get to place B, let's say it's skilled nursing or even home health. And when that nurse sees that wound, they see that the wound is 50% yellow slough and 50% red granulation. There's so much there that is a problem because did that patient decline from hospital to setting B? Did that patient decline in setting B because the nurse didn't see the wound for how many hours? Or is it that the hospital didn't know how to evaluate the tissue or that the nurse on admission didn't evaluate the tissue? The fix to that is imaging. That's a simple fix for a simple problem that we need a better solution for. But the implication there is that you had some potential decline, there's going to be finger pointing at somebody's direction, but also it could be that the nursing home, if they're the ones that are implicated in the issue, it could be that they failed to assess properly because what they wrote on admission was different than what was on discharge or that they caused a decline, which either one is a tag.
So having those tissue types is essential to protect yourself and your setting, but also to provide the patient the right information.
Catherine Milne:
So the imaging that you're talking about, does it usually tell you if it's granulation or slough or eschar?
Jeanine Maguire:
There's all different types of imaging. And if you are looking at doing imaging, which I think everybody should be doing imaging, it obviously needs to be HIPAA compliant, embedded in your EMR, all that good stuff. Some of it does suggest tissue types. FDA regs are really heavy in that area, so you want to evaluate this properly and make sure you have a tool that the human is deciding that it's accurate or not accurate at the end of the day, even if it's making suggestions. But what I'm suggesting is even before we had fancier tools that could do that for us, just having a wound specialist look at an image that's 100% red is really all you need as a starter.
Catherine Milne:
Yep. So let's kind of get into those tissue types demystified. So let's start with the big picture. Why is accurate identification of tissue types so critical in wound care? I know that in the first session we talked about it really helps you define that plan and then a little, you've touched a little bit on what the financial or implications for if you've done it wrong. Anything else that you can think of?
Jeanine Maguire:
Sure. So with a reimbursement for dressings and certainly there's nuance in different settings and so on, but let's say you have ability to get Part B reimbursement for your dressing. You have to specifically know the percentage, like is there slough or is it all granulated? How much drainage is there? So the tissue type helps you get the documented reimbursement you need for the treatment that you have selected. It also helps define the treatments that you select as well. And on top of that, tissue types also give you a clue as to whether or not that patient is progressing in the right direction through the phases of healing.
Catherine Milne:
Yeah. I think the people undervalue the importance of dressing application and reimbursement and it is confusing.
It's difficult, but I don't think it's something that should be discussed in the basic, basic orientation of anybody who is dealing with wounds, because that's so confusing. What do I put on if it's moderate drainage? What should I put on if it's slough? What can I get? What can't I get?
Jeanine Maguire:
Yeah. I'm excited though that the conversation is what should I put on? Because 20 years ago people were still doing things open to air, soaking it in water and all these other crazy things. Worldful. Yeah. All these things that I've done. So I'm really happy now people are saying, "What should I put on? How do I manage the drainage and what's the frequency of dressing change based on what's clinically appropriate, what you can do reimbursement wise, as you said, the amount of drainage, but also the bigger picture of the human. If that human is high risk of infection, their blood glucose is through the roof and they have no blood flow to that wound and that wound is covered with slough, please don't stick it under a dressing and not change it for a week or else you can ensure infection. So you have to go deeper than just the tissue.
Catherine Milne:
Yeah. So can you walk us through how you clinically distinguish between the most common tissue types, like between slough and eschar and granulation tissue and epithelial tissue?
Jeanine Maguire:
Do you remember back in the day the red, yellow, black? I mean, that was so basic and I feel like for a brand new clinician, it's a good starter. And so red, if it's viable and we often hear the term beefy red, but not friable. Meaning if you touch it, it doesn't bleed. So you take a moistened swab and gently touch that granulation, which usually looks kind of, as I said, beefy and budded and it doesn't bleed, that's likely healthy granulation. If you touch it in bleeds, it could be a sign of bioburden. If it's pale and dusky, something's not right there either. And by the way, if it's more striated tissue, like think about a piece of steak or something, like if it's striated and you touch it and it moves, it's probably muscle. So you do need to understand the difference between those tissues and granulation's probably one of the easier ones I think for me at least.
Now slough, which by the way, rhymes with rough. I hear a lot of people say that different ways. So slough tissue tends to be yellow. It can be gray. It can be thick or thin, adherent or loose, really stringy. You want to be as descript as possible because that will help you determine or your provider determine how should we clean that up because you don't need that wet and dead sitting in that wound. That's going to highly increase your risk of infection. And if that slough is very loose and stringy, it's a lot easier to use different modalities to debride that wound out. If that slough is really hard and really integrated with that wound and let's say the patient's on anticoags, maybe you don't want to do debridement with a sharp instrument. So the slough generally is pretty easy to see although sometimes you do have to be very aware of your anatomy because things that are yellowy white can also be things you don't want to cut like a ligament.
So you have to know your anatomy. And then lastly, I'll say eschar, which is generally pretty easy to recognize too, although people will confuse eschar from a scab. So eschar is thick and dead and it usually is black or brown. Sometimes it starts to hydrate and you can see slough at the edge as it's turning yellow, but this is replacing something and that something would be your epidermis and dermis. When you see that eschar, that is a full thickness wound. If you see a little scab that could indicate that somebody left that wound open to air and it just desiccated, but it's superficial or it's just dried up, desiccated drainage, but it doesn't indicate that you have a full thickness wound that you now have to take care of.
Catherine Milne:
Right. So in the definitions in long-term care for a stage two, the purple heel or hemorrhagic heel, because there's a difference between the regulations in long-term care as compared to what everybody else in the world uses, which is the NPIAP.
Jeanine Maguire:
There are subtle differences for sure. And I guess stage two is definitely it merits further conversation because a stage two is one of the few stages of a pressure injury where it is only partial thickness. So it is epidermis and dermis, but in definition it can look two ways. And this is true in PIP and MDS, REI, long-term care and home health. So it can look two different ways. It can look like a fluid filled blister that's clear, but the cause is pressure and with shear, right? You can't just get that blister without some sheer force here. So it's prolonged pressure and shear. It caused a separation between the epidermis and dermis, it filled up with fluid. So that's A, B is that it's open, but you're exposing the dermal tissue, which is not granulation. Now some people dispute that and I don't know where that's going to land, but right now in the MDS REI, you're supposed to call it open epithelium.
So that is confusing for a lot of people. But if you call it granulation, which is what most people do, then you've basically just described a stage three pressure injury according to the MDS.
And so the MDS coordinator or OASIS person filling that out, they have to know these tissue types and they have to understand staging according to that setting.
Catherine Milne:
I think the education of the people who fill out these documents for us is so important.
Jeanine Maguire:
It is, because they can catch issues.
Catherine Milne:
Yeah. But it has implications for A, the patient and B, the financial health of the institution.
Jeanine Maguire:
Yeah, absolutely. And C, and maybe you mean this, but a survey can go bad because of that and you have a bad survey, the next will come to litigation.
Catherine Milne:
So is there anything you do either tactilely with your fingers or with your hands or do you have any special instruments that help you differentiate between tissue types - anything that you think really matters?
Jeanine Maguire:
That's a really good question. I go back to the idea of the imaging again and getting a wound specialist eyes on that. And so somebody who's been trained in it and can really look at that image with good lighting and make sure that they agree on those tissue types. I feel like that's your biggest defense and having those photos in there. If you have that image in there and that admission nurse said it was a stage two, but the image clearly depicts slough, you can do a note of correction and refer back to that image on the date of admission and that's going to be okay. But if you don't have that image, then you're leaving it up to somebody else to interpret whether you did something wrong or right and it's probably not going to go in your favor.
Catherine Milne:
So when I'm at the bedside and not looking at imaging and I see something white, I always take some, if I have a probe or a Q-tip and actually touch it because if it's soft, it means one thing and if it's hard another.
Jeanine Maguire:
Yeah, I do that. And I would also recommend that as a PT, I know that you can just move the joint a little bit and you'll see a tendon move. You'll see the muscle move. It's very different than the way slough behaves. So again, it's understanding anatomy physiology.
Catherine Milne:
Yeah. Perfect. What kind of mistakes do you see clinicians make when identifying tissue?
Jeanine Maguire:
I see people erroneously calling scabs, unstageable pressure injuries. The opposite is also true. And it's always on a place where there is no pressure. Never pressure, right. I see people calling unstageable pressure injuries on a heel of somebody that is immobile, a scab. So I think it goes both directions and I don't think it's malintent. I think there really is a lack of knowledge most of the time. That's probably the biggest.
Catherine Milne:
So I'm kind of thinking about the staging issues that we see staff nurses, we have good documentation that staff nurses are not well versed in staging. Do you know of any literature that says the same thing about tissue types? Have we looked at people, how they're looking at tissue types and are they as inaccurate as staging is for a staff nurse? I
Jeanine Maguire:
Don't know the answer to that, but I can tell you that as we're moving into the area of training AI models to look at tissue types using only certified wound specialists, if you get the same responses 75% of the time amongst all wound specialists, that's pretty good. So my point is even for wound specialists, getting that nail down is a challenge. And so for somebody who has no training at all, it's a big issue.
Catherine Milne:
Yeah. So once you've identified the tissue correctly, how should that guide you in your next steps in managing the patient?
Jeanine Maguire:
Yeah. So once you've figured out the tissue types, that helps you identify what phase of healing that wound is in. So for example, if the wound has dead tissue in it, whether it's slough or eschar, you're not in proliferation. You still need to get rid of those necrotic tissues. You need to help that person get through the inflammatory phase. And in fact, let's say it is beautiful granulation this week and next week you have new slough. It's going the wrong direction. So it really helps you identify where that patient is on their trajectory of healing or not.
Catherine Milne:
Wonderful. That's been really, really incredible. One more thing because it's time for us to wrap up where you're going to ask for that wound to the wise. When it comes to tissue identification, what's one practical tip or mindset shift that a clinician can apply tomorrow because they are listening today, they should apply tomorrow.
Jeanine Maguire:
I think that really understanding where the wound is at. So when I do wound rounds, when I've done wound rounds in the day, whether it's virtually or in person, don't rely on your memory. You have to make sure you review the previous week documentation or image if you're lucky enough to have one before you go to that bedside so you can really determine whether or not that patient is improving or going backwards. Too often I see people go in and do rounds and they may not have been the same provider as the week before. And without having that knowledge, you don't know if that patient's stuck or going backwards. So you really need to dive in and see what the wound looked like previously before rounds and you need to know the simple things. What meds are they on? What's their blood glucose and so on before you make that decision of what to do next.
Catherine Milne:
Great. Well, thank you for sharing all your knowledge with us. This was really practical and helpful and I'm sure people listening today are going to listen today and apply tomorrow. If you're looking to strengthen your wound assessment skills and clinical confidence, be sure to explore additional education and tools available through WoundCon and WoundSource and stay connected with us on woundcon.com, SoundCloud, Spotify, and Apple Podcasts. Thank you for joining us today as we listen and apply tomorrow. Thanks, Jeanine.
Jeanine Maguire:
Thank you so much, Cathy. This was fun.