Last reviewed: October 23, 2026
In this article
A powered support surface request needs to answer two questions: what do your residents need, and what will the facility need to provide it reliably? The purchase price is only part of that discussion. The International Guideline makes it good practice for organizations to maintain an inventory of, or access to, a range of support surfaces suited to their clinical population. [1]
For a facility considering more powered surfaces, that is the starting point: identify the needs your current equipment can’t readily meet, then evaluate the options against those needs.
A 30-second read
Clinical takeaways
Cochrane 2021 · Low certainty (prevention) · Moderate certainty (cost)
Prevention and value
Compared with foam, alternating pressure may reduce new pressure injuries and is “probably more cost-effective” for prevention. [2]
SS1 · Good practice statement
Access to a range
The guideline makes it good practice to keep access to a range of surfaces — with “a larger range” where many residents are at high risk. [1]
A practical sequence
From need to request
Count residents needing reassessment, plan the full cost, and evaluate with your team before you request. [3]
Section 1 · Find the gap
Start with the gap between residents’ needs and your equipment.
- SS11 · SS15 · Conditional, very low certainty
- SS1 · SS12 · Good practice statements
- BC provincial guidance · 2017, 2026
Start with the residents. These clinical situations warrant a closer look at the support surface:
Recognize the need
Clinical situations that warrant surface reassessment
SS7 · Guideline evidence summary
Higher risk, or deteriorating skin or clinical condition
Alternating-pressure or reactive air surfaces are “usually reserved for individuals at higher risk or deteriorating skin condition or clinical condition.” [1]
SS11 · Conditional, very low certainty
Heat and moisture at the skin contribute to risk
A low-air-loss surface could be used, especially when heat and moisture at the skin–surface interface contribute. [1]
SS15 · Conditional, very low certainty
An existing Stage 2–4 or unstageable pressure injury
The guideline suggests low air loss for Stage 2–4 and unstageable pressure injuries. [1]
SS12 · Good practice statement
An injury that can’t be offloaded or isn’t healing
If the resident can’t be positioned off the injury, has injuries on two or more positioning surfaces, is failing to heal despite a comprehensive plan and optimal topical wound care, or is uncomfortable or bottoming out: review and adjust repositioning, then consider changing the surface. [1]
BC provincial algorithm · 2026
A non-heel injury with only 0–1 tolerated turning surfaces
BC’s algorithm points to an active air (alternating) surface with the alternating feature turned on, or a reactive air surface if active air isn’t tolerated, available or comfortable. [4]
Individual assessment guides each choice (SS4). Moisture from incontinence or wound exudate alone does not call for low air loss. [1]
A practical moisture prompt: is the resident’s Braden moisture score prompting an equipment assessment as well as a skin-care plan? BC’s 2017 Braden interventions guide suggests considering a low-air-loss surface or microclimate manager when the moisture subscale is 2 or less. [5]
Then check what your facility can provide. “We need more powered mattresses” is a starting point. A stronger request explains which needs are hard to meet, how often they arise, and what happens while appropriate equipment is being arranged.
Review a recent period with your clinical and purchasing teams. Record requests for a different surface, whether suitable equipment was available, how long it took to obtain, and the reason for each request. Use de-identified information in purchasing discussions.
What current guidance says about access
SS1 · Good practice
A larger range for higher-risk residents
“Where there is a high proportion of individuals at high risk of (or with) a PI, the health service should have a larger range of support surface options.” [1]
BC provincial algorithm · 2026
Know what your facility can access
BC’s provincial algorithm asks sites to document available surfaces and resources across its categories, including active air. [4]
If a resident needed an active-air surface tomorrow, how quickly could your team provide it?
Timing matters. In long-term care, pressure injuries are “most likely to develop within the first four weeks” after admission, and Accreditation Canada recognizes pressure-injury prevention and management as a measure of quality in long-term care. [6] Pressure ulcers are also publicly reported: CIHI compares long-term care organizations’ rates of worsened Stage 2–4 pressure ulcers with the national average. [7] Framing the request as part of your quality-improvement plan makes it easier to justify, and easier to measure.
| Function | What it does |
|---|---|
| Alternating pressure | An active surface: cyclic inflation and deflation change which areas carry load over time, rather than relying only on the person changing position. [8] |
| Low air loss | A feature that uses a flow of air to assist pressure redistribution and may help manage heat and humidity at the skin–surface interface. [8] |
Some surfaces combine both, so clinicians can consider pressure redistribution and microclimate needs together when selecting a surface. [1]
Section 2 · When powered surfaces help
Where powered surfaces fit: prevention and healing.
- Prevention · Cochrane 2021 · Low certainty
- RCT · older residents in long-stay care
- SS12 · Good practice statement
Alternating pressure may reduce new pressure injuries
Estimated people developing a new pressure injury per 1,000
- Alternating pressure: 67 per 1,000
- Foam reference: 106 per 1,000
An estimated
39 fewer
people per 1,000 with alternating pressure than with foam
Cochrane network meta-analysis, alternating pressure versus foam
Network estimate · Low certainty · median follow-up 14 days · 95% CI 8 to 62 fewer. Not an annual rate.
Shi et al., Cochrane Database Syst Rev 2021 [2]
Sauvage et al., 2017 · Randomized trial · France
2 of 39 vs 13 of 37
Residents with a new pressure injury within 30 days · alternating-pressure air mattress vs high-specification viscoelastic foam
- Residents
- 76 people aged 70 or older in nine French medium- and long-stay care facilities, bedridden at least 15 hours a day with little or no ability to reposition themselves, at moderate to high risk (mean Braden score about 12), skin intact at the start.
- Finding
- New pressure injuries of any stage, including Stage 1, in 2 of 39 residents on alternating pressure versus 13 of 37 on viscoelastic foam. Preventive care was similar in both groups, and residents rated comfort high on both surfaces.
- Repositioning
- Turning averaged fewer than two times a day in both groups. The authors conclude that when a resident can’t reposition themselves and staff can’t reposition them at least every four hours, day and night, an alternating-pressure mattress “is an effective alternative” to viscoelastic foam.
- Context
- A small, open-label trial, and one of the trials within the Cochrane evidence above rather than separate confirmation of it.
Canada’s health-technology agency reached a similar conclusion. CADTH’s 2022 review found that alternating-pressure air surfaces — like reactive air and reactive gel surfaces — “may be more effective at preventing pressure injuries compared to foam surfaces.” [11]
For a resident who already has an injury, the guideline is direct:
“Unless the individual’s clinical condition has changed (e.g., the individual has regained mobility, consciousness, and has adequate perfusion), the support surface on which a PI developed usually does not provide an appropriate environment for healing. A different support surface will usually be required to provide better pressure redistribution (i.e., envelopment and immersion) friction and shear force management and modification of the microclimate.”
International Guideline, 4th ed. · Full Body Support Surfaces · SS12, p. 14 [1]
Good practice statement. Review and adjust the repositioning regimen before considering a surface change.
9.0 vs 2.5 mm²/day
Median wound-area reduction · low-air-loss bed vs 10-cm convoluted foam overlay
One randomized trial in nursing homes: 84 residents with existing trunk or trochanter pressure injuries, published in 1993. Wound-area reduction, not time to complete healing.
Section 3 · The economic case
The economic case for prevention.
- Cochrane 2021 · “probably more cost-effective” · Moderate certainty
CA$44,000–90,000
Total net hospitalization cost per hospital-acquired Stage 2–4 pressure injury
Ontario hospital data, older inpatients, 2002–2006. Context, not a savings projection.
Chan et al., 2013, as reported by RNAO and Wounds Canada [14][6]
“The equipment and interventions required to prevent pressure injuries are less expensive than the cost of treatment.”
Wounds Canada · Best Practice Recommendations 2025 · Chapter 7, p. 3 [6]
Cost-effectiveness evidence
Cochrane concluded that alternating-pressure air surfaces are probably more cost-effective than foam for preventing pressure injuries.
Moderate certainty · one UK trial-based economic evaluation · acute and community inpatients
UK trial-based estimate; results varied in sensitivity analyses. Use local costs for your facility’s budget.
For the purchasing meeting, this is a published economic reason to include alternating pressure in the assessment. Put prevention equipment and the resources used in pressure-injury care into the same discussion — wound-care supplies, staff time, equipment rental and maintenance — using your facility’s own records.
Section 4 · The full cost
Compare the full cost, not just the price.
- Wounds Canada · cost effectiveness, not straight cost
Two quotes may cover different things. Before comparing prices, ask each supplier for the same information over the same evaluation period. As Wounds Canada puts it, “cost effectiveness, rather than straight cost, should be considered in conjunction with patient satisfaction and care provider satisfaction.” [6]
Purchasing worksheet
What belongs beside the price?
| Include | Questions for the facility and supplier |
|---|---|
| Acquisition or rental | What is included? Which sizes and accessories are needed? What are the delivery, warranty and rental terms? |
| Rental versus ownership | If you rent specialty surfaces when a resident’s needs change, total last year’s rental days and costs, and compare them with owning the units you use most. |
| Training | Who trains day, evening and night staff? Are current instructions and a return-demonstration checklist provided? |
| Routine operation | Which settings are automatic? Which checks remain staff responsibilities? |
| Staff safety | Will the surface help staff reposition residents safely? The guideline notes that where an adequate turn angle and offloading can be achieved, turn-assist features “might reduce the occupational health and safety risk with repositioning.” [16] |
| Cleaning and maintenance | Which cleaning products and processes are compatible? What needs inspection or replacement, and how often? |
| Service and availability | How are faults reported? What are the response times, parts availability and replacement-equipment arrangements? |
| Power and space | Are there reliable outlets, a place for the pump, and an outage plan? |
| Fit and setup | Does the surface fit the bed and the resident? Are bedding and required monitoring equipment compatible? |
| Replacement | What is the expected functional lifespan, and is there a replacement program? |
An Evergreen planning checklist, not a validated economic model.
Section 5 · Demonstrate and decide
Turn the request into a focused evaluation.
- NPIAP S3I · Support surface selection steps
Step 1 · Demonstrate
Will our staff use it confidently?
Involve the nurses, PSWs and therapists who will use it every shift. Practise setup, selecting the prescribed mode, checking support, using care functions and finding the emergency instructions. Teach from the current manual for the exact model. BC’s algorithm reminds teams to make sure the alternating feature is turned on when it’s needed. [4]
Step 2 · Evaluate
Does it meet our residents’ needs?
Agree on resident selection, clinical oversight, measures and a review date before you start. Facilities “may decide to evaluate a product and receive feedback from patients and bedside clinicians.” [3] Keep each resident’s repositioning plan in place. [16]
Step 3 · Decide
What exactly are we asking for?
Bring a one-page summary and “collaborate with Administration regarding procurement of recommended surface.” [3]
Worksheet
Count residents needing surface reassessment.
| Situation | Residents now |
|---|---|
| Higher risk, or deteriorating skin or clinical condition | ______ |
| Heat and moisture at the skin contributing to risk | ______ |
| Existing Stage 2–4 or unstageable pressure injury | ______ |
| Can’t be positioned off an injury, or injuries on two or more positioning surfaces | ______ |
| Not healing despite a comprehensive plan, uncomfortable, or bottoming out | ______ |
| Total residents (count each resident once) | ______ |
Residents may appear in more than one row: count each resident once in the total rather than adding the rows. This is a needs-assessment worksheet, not a mattress-order calculation.
Download the one-page request worksheet (PDF): the resident count, what your facility can access today, the full-cost checklist, an evaluation plan and the request, ready to print or forward.
For your purchasing team
A one-page summary
What to include
- The clinical and access gap being addressed.
- The surface functions required, and why.
- The proposed purchase or rental arrangement and its full cost.
- The training, maintenance and service plan.
- The evaluation measures, responsible clinician and review date.
Afterwards, track the share of residents with “appropriate support surfaces based on their assessment”, Ontario Health’s quality indicator. [17]
Section 6 · From Evergreen
Smart features designed to simplify everyday care.
- Equipment information · not study evidence
Set up once, then it runs
Smart features simplify setup and operation. Auto-Detect sets pressure automatically based on the resident’s weight and body surface area; once the initial setup is complete, the surface continues operating without the need for routine caregiver adjustments. On OpalAir and OpalAir Turn, Auto-Fowler automatically adds air when the bedhead is raised. When care requires a firmer surface, Auto-Firm fully inflates the cells for repositioning, transfers or personal care, then automatically returns to the previous therapy mode after twenty minutes.
Palm, OpalAir and OpalAir Turn combine alternating pressure with low air loss in one surface. Evergreen describes Palm’s feature as “micro low air loss” and the OpalAir models’ as “true low air loss”; these are product descriptions, not evidence grades. Their automatic functions are designed to make setup and day-to-day operation simpler for care teams. The descriptions below are specific to Evergreen’s surfaces; automatic features vary between brands, so ask each supplier what its surface does automatically.
What the surfaces handle
Palm · OpalAir · OpalAir Turn
Auto-Detect
Automatically calibrates optimal pressure based on bodyweight and surface area. This improves the efficiency of set-up, reducing the need for on-going caregiver adjustments.
Palm · OpalAir · OpalAir Turn
Automatic alternating-pressure cycles
Once set up, alternating-pressure cycles run automatically, without staff operating each cycle.
OpalAir · OpalAir Turn
Auto-Fowler
Automatic increase of air to the sacral/pelvic area when the bedhead is raised, to reduce risk of bottoming-out and ensure protection for high-risk bony areas.
Palm · OpalAir · OpalAir Turn
Auto-Firm
Mattress cells inflate to max for caregiver management. After 20 minutes the system automatically returns to the previously selected therapy mode.
During a demonstration, ask a staff member to show the setup back, and agree what the next shift needs to know.
Evaluate before you commit. Evergreen connects you with the authorized dealer in your region within 1–3 business days for an in-person or virtual demonstration. Demo units are available subject to availability, dealer demos run on a 30-day return window, and if you keep the unit, its warranty starts on the purchase date.
Support after purchase: a 1-year warranty on pump and mattress, OEM parts guaranteed available for 5 years from purchase, free remote troubleshooting throughout the parts period, and no-charge in-services for your team. Warranty details.
Bring your equipment question to a demonstration
Considering more powered surfaces for your facility?
Bring your clinical requirements, bed configuration and day-to-day care questions. We’ll connect you with your regional dealer within 1–3 business days, walk through setup and operation with your team, and help gather what you need for a facility evaluation.
About Evergreen. An Evergreen educational summary of published studies and guidelines. Practical examples illustrate application. The sources do not endorse Evergreen or its products. Support surfaces do not replace repositioning. Selection and use should be based on individual clinical assessment and the product instructions for use.
Explore Evergreen’s powered surfaces.
These links describe Evergreen’s range. They are not study endorsements or product-specific evidence.
References
- National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Full Body Support Surfaces. In: Haesler E, ed. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. 4th ed. 2026. Version date 20 May 2026 (site updated 25 August 2026). SS1, SS4, SS7, SS11, SS12, SS15; pp. 2–3, 6, 9, 13–14, 16. https://www.internationalguideline.com/surfaces
- Shi C, Dumville JC, Cullum N, Rhodes S, McInnes E, Goh EL, Norman G. Beds, overlays and mattresses for preventing and treating pressure ulcers: an overview of Cochrane Reviews and network meta-analysis. Cochrane Database Syst Rev. 2021;(8):CD013761. doi:10.1002/14651858.CD013761.pub2. Abstract p. 2; Table 2, pp. 35–36. https://pmc.ncbi.nlm.nih.gov/articles/PMC8407250/
- National Pressure Injury Advisory Panel, Support Surface Standards Initiative. Support Surface Selection Steps (poster). 2020. https://npiap.com/page/S3I
- BC Provincial Interprofessional Skin & Wound Committee. BC Provincial Support Surface Mattress Algorithm (Adult Populations). June 2026. pp. 1, 4. https://www.clwk.ca/get-resource/bc-provincial-support-surface-selection-qrg/
- BC Provincial Interprofessional Skin & Wound Committee. Braden Scale Interventions Guide – Adult. July 2017 (moisture subscale of 2 or less). https://www.clwk.ca/get-resource/braden-scale-interventions-for-adults-guide/
- Norton L, Parslow N, Ho C, O’Sullivan-Drombolis D, Rogers A, Parsons A, Moss L. Best practice recommendations for the prevention and management of pressure injuries. In: Best Practice Recommendations for Skin Health and Wound Management 2025. Toronto: Wounds Canada; 2025. Chapter 7, pp. 3, 19, 22, 36. doi:10.56885/GRYI5585. https://www.woundscanada.ca/health-care-professional/publications/bpr-new
- Canadian Institute for Health Information. Worsened Pressure Ulcer in Long-Term Care (indicator PRU06). Data updated January 2026; results on CIHI’s long-term care dashboard. https://www.cihi.ca/en/indicators/worsened-pressure-ulcer-in-long-term-care
- National Pressure Injury Advisory Panel, Support Surface Standards Initiative. Terms and Definitions Related to Support Surfaces. Rev. 18 April 2024 (PDF unpaginated; cited by PDF page). https://npiap.com/page/S3I
- Sauvage P, Touflet M, Pradere C, et al. Pressure ulcers prevention efficacy of an alternating pressure air mattress in elderly patients: E²MAO a randomised study. J Wound Care. 2017;26(6):304–312. doi:10.12968/jowc.2017.26.6.304. PMID: 28598759. Turning frequency, Table 3 (p. 309); authors’ conclusion and limitations, pp. 311–312. Study characteristics and results are also reported in Cochrane CD013620 (reference 10).
- Shi C, Dumville JC, Cullum N, Rhodes S, Jammali-Blasi A, McInnes E. Alternating pressure (active) air surfaces for preventing pressure ulcers. Cochrane Database Syst Rev. 2021;(5):CD013620. doi:10.1002/14651858.CD013620.pub2. Characteristics of included studies: Sauvage 2017, pp. 115–118; Analysis 1.1. https://pmc.ncbi.nlm.nih.gov/articles/PMC8108044/
- Vu T, Askin N. Therapeutic Support for Pressure Injuries. CADTH Health Technology Review RC1450. Can J Health Technol. 2022;2(9). p. 6. canjhealthtechnol.ca/index.php/cjht/article/view/RC1450
- Shi C, Dumville JC, Cullum N, Rhodes S, Jammali-Blasi A, Ramsden V, McInnes E. Beds, overlays and mattresses for treating pressure ulcers. Cochrane Database Syst Rev. 2021;(5):CD013624. doi:10.1002/14651858.CD013624.pub2. https://doi.org/10.1002/14651858.CD013624.pub2 — “Characteristics of included studies: Ferrell 1993” (in the full Cochrane record). Narrative also at https://pmc.ncbi.nlm.nih.gov/articles/PMC8108042/
- Ferrell BA, Osterweil D, Christenson P. A randomized trial of low-air-loss beds for treatment of pressure ulcers. JAMA. 1993;269(4):494–497. doi:10.1001/jama.1993.03500040060037. PMID: 8338511. Abstract: https://jamanetwork.com/journals/jama/article-abstract/403027 — study characteristics and results are also reported in Cochrane CD013624 (reference 12).
- Registered Nurses’ Association of Ontario. Pressure Injury Management: Risk Assessment, Prevention and Treatment. 4th ed. RNAO; 2024 (2025 web update). p. 25 (reporting Chan et al., 2013).
- Nixon J, Brown S, Smith IL, et al. Comparing alternating pressure mattresses and high-specification foam mattresses to prevent pressure ulcers in high-risk patients: the PRESSURE 2 RCT. Health Technol Assess. 2019;23(52). Economic evaluation, pp. 53–61, 85. doi:10.3310/hta23520
- National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Repositioning and Mobilization. In: The International Guideline. 4th ed. 2026. Version date 14 May 2026. R1, R3 (turn assist); pp. 1, 5. https://www.internationalguideline.com/repositioning
- Ontario Health (Health Quality Ontario). Pressure Injuries: Care for Patients in All Settings. Quality Standard; 2017. Quality Statement 5; process indicator, p. 22. hqontario.ca/Evidence-to-Improve-Care/Quality-Standards/View-all-Quality-Standards/Pressure-Injuries
Continue the clinical pathway
This article is an educational resource for healthcare professionals. It is not intended to replace clinical judgment, individualized resident assessment, facility policy, or product instructions for use.