We present an analysis of the risk factors, the origin and the nursing and medical practice of 140 deaths with high-grade pressure sores which had been detected by post-mortem examination before cremation. METHODS: All available nursing and medical records from nursing homes and hospitals were screened; in addition, relatives and head nurses were interviewed. The data sources were screened for individual risk factors, information about pressure sore prevention and treatment activities by nursing staff and general practitioners. Moreover, the utilization of pressure relieving devices for patients before and after development of the final decubitus was analyzed. RESULTS: More than 50% of the pressure ulcers had been incident in nursing homes. The mean duration of the disease was 307 days (median duration 123 days); the maximum duration ranged up to about 6 years. As far as it could be judged from the nursing records, there was a shortfall of nursing quality in terms of prevention efforts which appeared to be frequently inadequate in relation to the risk profile of the residents. Standardized pressure sore record files were missing in most of the cases. General practitioners were not involved in the treatment in 20% of all cases; some of them prescribed an obsolete wound management. In this study 52% of the patients had been classified into the maximum grade within the three-stage German nursing care insurance scheme. In cases of private care information about utilization of financial support and of professional help should be enforced. DISCUSSION: Being an indicator of nursing quality, shortfalls of prevention measures should be combatted by a broad pattern of quality management strategies which could be adapted from the clinical sector.
