The International Pressure Injury Guideline in 2026Practical Lessons for Canadian Care

A resident’s needs can change before their mattress, repositioning schedule or seating plan does. Less movement, a change in skin condition, difficulty tolerating a position or a new moisture problem are reasons to look again — not simply to continue the routine. The fourth edition of the International Pressure Injury Guideline, released in chapters through 2025 and 2026, is most useful read as the set of questions to ask when that happens.

This article draws five lessons from the chapters on full body support surfaces, repositioning and mobilization, seating and heel pressure injuries. [1][2][3][4] It is a practical reading of what the current chapters say, not a line-by-line comparison with the 2019 edition. Certainty labels are the guideline’s own: a strong recommendation means the panel is confident most people should receive the intervention; a conditional recommendation depends on the individual; a good practice statement is accepted practice where trials are unlikely. Strong recommendations are few — pressure-redistribution foam for people at risk, and a pressure-redistribution seating surface for people who are seated — and most of the guidance is conditional or good practice, which is why every lesson below ends in assessment.

The guideline strongly recommends a pressure-redistribution foam (reactive) full body support surface for individuals at risk of pressure injuries (SS3), despite low-certainty evidence. The panel explains that it made the recommendation strong “because the risk of harm in not using a full body support surface with pressure redistribution features for individuals at risk of PIs is very high,” and that modelling in aged care found the move to pressure-redistribution foam “has a high likelihood of being cost effective.” [1] This is not a recommendation for any mattress labelled foam: the pressure-redistribution characteristics are the point. The comparison behind SS3 is with foam surfaces without pressure-redistribution properties; it does not establish that foam outperforms alternating pressure or low air loss surfaces. Those comparisons are the conditional statements in Lesson 2. [1]

Selection then follows the person. SS4 names the factors: overall risk, the response of the skin and tissues, independence, mobility and activity, “posture and sleeping position and their effects on pressure redistribution,” the “need for microclimate management and shear reduction features,” and preferences and care goals. [1] Two good-practice statements add the practical layer. SS1 asks organizations to keep an inventory of, or access to, a range of surfaces appropriate to the setting, “maintained, stored and used in accordance with manufacturer recommendations,” with mattresses and overlays correctly fitted to the bed to avoid entrapment or falls, overlay height checked against side-rail standards, and equipment inspected “at least daily while in use.” SS2 asks for a surface or integrated bed system that accommodates the individual’s weight, height, size and body-mass distribution. [1]

For people at risk, the guideline conditionally suggests either alternating pressure air or pressure-redistribution foam (SS6, low certainty), either air (reactive) surfaces or foam (SS5, very low certainty), and either alternating pressure or air (reactive) surfaces (SS7, very low certainty). Air (reactive) surfaces include both powered low-air-loss designs and non-powered static-air surfaces; the analyses behind SS5 and SS7 excluded low air loss surfaces, which the chapter evaluates separately (SS11). [1] The evidence limits matter here: the guideline’s pooled comparison of alternating pressure with foam for prevention did not reach statistical significance, and the certainty is low. These are options to match to a person, not a ranking. [1] The chapter does say where alternating pressure may earn its place: “for individuals at the highest PI risk (e.g., individuals in critical care) or for those seeking an alternative support surface option for comfort or when less frequent repositioning is the individual’s preferred option (e.g., palliative or end-of-life care),” and it records that in several studies individuals reported “easy bed movement and less pain” on alternating pressure surfaces. [1]

When an injury already exists, SS12 asks for the surface to be re-evaluated, with the repositioning regimen reviewed first, because “the support surface on which a PI developed usually does not provide an appropriate environment for healing.” [1] Its implementation guidance names four situations in which to consider a change:

For Stage 2 to 4 and unstageable injuries, the guideline conditionally suggests either foam or alternating pressure (SS13) and, separately, low air loss (SS15), both on very low certainty. A heel injury may not need a surface change at all if an offloading device manages it. [1] Stage describes tissue involvement; it does not by itself determine the support surface. Mobility, offloading, moisture, comfort and the healing trajectory do.

Alternating pressure changes where load is carried over time. Low air loss is a construction that, in the Support Surface Standards Initiative definition the guideline adopts, uses a flow of air “to assist in pressure redistribution and may assist in managing the heat and humidity (microclimate) of the skin.” [1][5] They describe different functions, and a surface may offer one or both.

The guideline conditionally suggests a low air loss surface for people at risk “especially when moisture and heat at the skin-surface interface are contributing factors” (SS11) and for existing Stage 2 to 4 injuries (SS15), both on very low certainty; the limits of that evidence are set out in the note below. [1] Because low air loss is a design feature rather than a measured performance, the chapter, citing S3I, encourages clinicians to look beyond the label and “use the results of standardized performance characteristic test data related to pressure redistribution and microclimate management to make an informed decision,” “rather than relying on a specific design feature.” [1][5]

R1 is explicit: repositioning is good practice “regardless of the type of pressure redistribution full body support surface being used”; the interval “might be adjusted depending on the pressure redistribution capabilities of the support surface and the individual’s response”; and “no support surface can entirely replace repositioning.” [2] R5 lists what sets the interval: activity and mobility, ability to self-reposition, skin and tissue tolerance, clinical condition, comfort, sleep patterns, goals of care, and the support surface in use. [2]

The frequency statements are conditional and candid. R7 suggests two- or three-hourly repositioning for most people at risk “if they are also on an appropriate pressure redistribution full body support surface”; R8 suggests not routinely extending to four, five or six hours. Both are very low certainty: the pooled comparison behind them found 4.6% versus 5.7% injuries, a difference the panel says gives “very little confidence.” [2] The implementation notes also ask teams to weigh “un-interrupted sleep versus more frequent PI preventive care” with the person and their carers, and to revisit that balance as priorities change. [2] Installing an air surface is not, by itself, permission to lengthen the interval; the person’s response is.

On technique, R10 suggests 30-degree lateral positioning (conditional, very low certainty), individualized so the sacrum and trochanter are both offloaded, with other prominences protected “using appropriate repositioning devices.” R3 makes equipment that reduces friction and shear during repositioning good practice; the chapter lists “mechanical lifting devices, transfer sheets, lateral air transfer devices, turn systems/devices, low friction fabrics” among that equipment, and its implementation notes add “lift rather than dragging,” attention to the heels during transfers, not leaving manual handling equipment under the person after use unless it is designed for that, and safe-handling procedures set locally. [2] Turn-assist surfaces are addressed directly: where adequate turn angle and offloading can be achieved, turn assist “might reduce the occupational health and safety risk with repositioning,” and automated turning may suit people who need frequent repositioning or have limited access to help. The caution comes in the same breath: “The turn feature does not allow the body’s posterior to ever be entirely free from contact with the support surface. Continue to assess the skin at regular intervals and evaluate whether offloading is truly occurring without shear.” [2]

Canadian guidance shares the assessment principles and differs on interval wording. Ontario Health’s quality standard measures repositioning every 4 hours for long-term care residents at lower risk (Braden 10 or higher) who have a high-density foam mattress, and every 2 hours for residents at higher risk, and asks that support surfaces be provided “based on their assessment.” [7] Wounds Canada’s 2025 recommendations note that a pressure-redistributing surface “does not eliminate the need for repositioning, but it may extend the length of time before repositioning is required,” guided by the skin’s response. [6] RNAO’s fourth edition suggests repositioning people at risk every 2 to 4 hours and made no recommendation for or against powered surfaces, judging the evidence insufficient to balance benefits and harms. [8] Where interval wording differs, the 2026 chapters are the current international reference; provincial standards and facility policy govern practice.

Prevention does not end when the person leaves the bed. The Repositioning chapter’s implementation guidance asks teams to “consider an individual’s positioning needs over a 24-hour period,” including “where and when they sleep, lie and sit,” with planning that “addresses body symmetry and postural support.” It describes positioning devices that “can assist in maintaining positioning, be used to elevate parts of the body off the support surface, and can promote body symmetry, posture and comfort,” placed so they do not load the very area meant to be relieved. [2]

The Seating chapter carries the second strong recommendation — a seating support surface with pressure-redistribution properties for people with or at risk of pressure injuries when seated (S2, moderate certainty) — and asks clinicians to “consider an individual’s posture over a 24-hour period, including where they sleep, sit, stand and walk” and to “integrate the use of different positions between the bed and the chair/wheelchair.” [3] S2 concerns the pressure-redistribution properties of the seat surface itself — in every study behind it the comparator was a foam cushion without pressure-redistribution properties [3] — so it is not evidence for positioning supports in general. For positioning supports, the relevant guidance is the positioning-device and 24-hour planning guidance above. The heels chapter’s first statement is good practice: elevate the heels so they are not in contact with the support surface, with a heel offloading device suited to the person’s mobility where appropriate. [4] A 2023 scoping review supports treating lying, sitting and standing as one coordinated framework while noting that outcome evidence remains limited; the practical response is to connect the assessments and monitor the results. [9]