Last reviewed: September 11, 2026
In this article
Pressure injuries remain one of the most preventable complications in Canadian long-term care.
“Stage 3 and 4 hospital-acquired pressure injuries — "Never Events."”
Never Events for Hospital Care in Canada · CPSI / HIROC [2]
Foam’s role · TEAM-UP Trial · 2022
Foam is the foundation — appropriately so.
- SS3 · Strong recommendation, low certainty
For most Canadian LTC facilities, foam surfaces are the foundation of pressure injury prevention — and appropriately so. The current International Guideline (4th ed., 2026) recommends a pressure-redistribution foam surface as the first choice for individuals at risk — and is explicit about the next step: alternating pressure (active) air or air (reactive) surfaces “are usually reserved for individuals at higher risk or deteriorating skin condition or clinical condition.” Its selection factors are overall risk of pressure injuries, skin and tissue response, mobility and independence, posture and sleeping position, the need for microclimate management and shear reduction, and preferences and care goals — not stage alone. [9]
High-specification foam, matched to a structured repositioning program, performs well for residents at low-to-moderate risk. Surface specification matters — and so does matching the resident to the surface.
TEAM-UP trial · Yap et al., 2022
0.0%
New pressure injury incidence
- Population
- Residents without existing pressure injuries and not at severe risk (Braden ≥10); 992 residents analysed.
- Setting
- Nine U.S. nursing homes; all residents on viable 7-inch high-density foam; 2-, 3- and 4-hour repositioning intervals over a 4-week study window.
- Finding
- No new pressure injuries during the intervention (0.0%), compared with 5.24% at baseline.
- Limitations
- Four-week window; the authors state that a causal link between repositioning interval and outcome was not established. Foam surfaces only — the trial did not compare surface types.
Yap et al., 2022 · Advances in Skin & Wound Care [3]
Limits and reassessment · Three limits of foam-only surfaces
But foam has limits.
01 · Immobility
It does not actively redistribute pressure.
Foam is a reactive surface: by definition it changes its pressure-redistribution properties only in response to the load placed on it. When a resident cannot reposition independently, relief over time depends on the repositioning plan rather than on the surface. [14]
02 · Degradation
It degrades without visible indication of failure.
Foam breaks down over time. A mattress that looks intact may no longer be providing the pressure redistribution it was specified to deliver.
03 · Microclimate
It offers no active microclimate management.
For residents with incontinence, diaphoresis, or heavy wound exudate, heat and moisture at the skin interface become a selection factor in their own right. Unlike a low air loss construction, foam does not use a flow of air to help manage heat and humidity at the skin; the guideline lists the need for microclimate management among its selection factors and names it as a reason to consider a low air loss surface (SS11, conditional, very low certainty). [12][9]
At the bedside · When to reassess the surface
Changes in the person
- The resident cannot reposition independently.
- Skin or wound status is deteriorating despite an individualized prevention plan.
- Pressure injuries are present on multiple positioning surfaces.
- Significant perspiration, incontinence or exudate burden is not contained by dressings or absorptive products.
Current surface performance
- The surface is bottoming out, or its performance is in doubt.
Positioning and the wider care plan
- The resident cannot be positioned off an area of concern.
- Consistent positioning cannot be maintained across shifts.
Any of these findings is a prompt to reassess the person, the repositioning plan and the support surface together — not an automatic surface change. No support surface replaces individualized repositioning, skin assessment, wound care, nutrition and ongoing monitoring.
Evidence for escalation · CADTH 2022 · PRESSURE 2 · 2019
What the evidence on escalation shows.
A 2022 CADTH rapid review found that reactive air surfaces and alternating-pressure active air surfaces may be more effective than foam at preventing pressure injuries — with effectiveness influenced by care setting and follow-up time. The evidence is strongest for prevention; comparative evidence for treatment is less certain. [4]
“Select an active support surface if the individual cannot be positioned without pressure on an ulcer, when a reactive support surface bottoms out, if there is no evidence of ulcer healing, or if new ulcers develop.”
Canadian Best Practice Guidelines · Pressure Ulcers in People with Spinal Cord Injury
Houghton, Campbell & CPG Panel · Ontario Neurotrauma Foundation · 2013 [5]
Written for spinal cord injury care — among the most evidence-dense pressure injury literature. Its escalation triggers are widely used as practical bedside logic beyond SCI, applied through individual clinical assessment.
PRESSURE 2 trial · Nixon et al., 2019
5.2% vs 7.8%
New Category 2 or worse pressure injuries while on the assigned surface · alternating pressure vs high-specification foam
- Population
- 2,029 high-risk inpatients.
- Setting
- 42 secondary and community inpatient facilities in the UK; alternating pressure mattresses compared with high-specification foam.
- Finding
- The 30-day primary result did not reach statistical significance (6.9% vs 8.9%). While participants remained on their allocated mattress, alternating pressure was associated with significantly fewer new injuries (HR 0.66, 95% CI 0.46–0.93; p = 0.018) — one injury avoided for every 38 people allocated.
- Limitations
- The primary endpoint was not significant; the on-surface result is a sensitivity analysis. Acute-care inpatients, not long-term care residents.
Nixon et al., 2019 · Health Technology Assessment [10]
The participants who benefited most were those who were completely immobile, had altered skin or a Category 1 injury at baseline, had a nutritional problem, or lacked capacity — the same findings that prompt a surface reassessment at the bedside. In practice, when a participant's clinical condition deteriorated, ward teams moved them from foam to alternating pressure. [10]
Heat and moisture · Saskatchewan Health Authority · CS-A-0018
For residents with moisture burden.
- SS11 · Conditional, very low certainty
Low air loss is the design feature built for this. The Support Surface Standards Initiative defines it as “a support surface construction that uses a flow of air to assist in pressure redistribution and may assist in managing the heat and humidity (microclimate) of the skin,” and the Cochrane overview notes such surfaces “are designed to improve the skin microclimate with the aim of maintaining skin and tissue integrity, particularly in people with incontinence.” The 2026 International Guideline suggests a low air loss surface “could be used for individuals at risk of pressure injuries, especially when moisture and heat at the skin–surface interface are contributing factors” (conditional recommendation, very low certainty of evidence). [12][13][9]
“A support surface that dissipates moisture — low air loss — may be indicated for a diaphoretic patient or a patient with copious wound drainage or incontinence not contained by dressings or absorptive products.”
Saskatchewan Health Authority · Support Surface Selection Algorithm · CS-A-0018 [6]
The 2024 RNAO guideline (4th ed.) affirms that surface selection must remain individualized — powered surfaces carry distinct clinical considerations that require assessment at the resident level. Escalation is a clinical decision, not a default. [7]
Costs and care planning · TEAM-UP economic analysis · Padula et al., 2024
Repositioning intervals change the nursing-time math.
$44K–$90K
Net hospitalization cost · per hospital-acquired Stage 2–4 pressure injury
Among older inpatients in an Ontario acute-care costing study. Prevention costs a fraction of treatment. Staging follows NPIAP terminology — Stage (Arabic numerals); the source study writes Category. Costing data are from acute care; comparable LTC-specific Canadian costing is limited — the direction of the number is the point.
Chan et al., 2013 [1]
$11.05–$16.74
Lower repositioning cost · per resident · per day (CAD)
For 3- and 4-hour repositioning regimens versus 2-hour — with no observed difference in injury incidence — on high-density foam in the U.S. TEAM-UP trial. Savings driven mostly by the value of freed nursing time.
Padula et al., 2024 [8]
This is not a small number. At facility scale, it represents meaningful reallocation of nursing time toward higher-acuity care priorities — wound assessment, care planning, and the complex residents who need the most.
The cost case for escalation is unusually well supported. The 2021 Cochrane review of alternating pressure surfaces reached a moderate-certainty conclusion: alternating pressure (active) air surfaces “are probably more cost-effective than foam surfaces.” In the PRESSURE 2 economic analysis behind that judgment, the alternating pressure arm had lower mean total costs (£4,533 vs £4,646) and marginally higher quality-adjusted life-years (0.128 vs 0.127), making it cost-effective with 99% probability at the UK willingness-to-pay threshold. [10][11]
The relevance for Canadian LTC
Appropriate surface selection is part of what makes longer, evidence-based repositioning intervals clinically defensible — and that is where the nursing time comes back.
Surface selection is both a clinical imperative and an operational one.
One more dimension belongs in the plan: the support surface manages the bed interface, while positioning supports extend the individualized plan across lying, seated and transitional positions. Both belong in a 24-hour approach.
Surface selection is among the most consequential clinical decisions in LTC pressure injury prevention — matched to resident risk, wound status, and microclimate need.
Cochrane 2021 · International Guideline 2026
Escalation is a clinical decision, not a default.
Clinical takeaway
Alternating pressure may reduce pressure-injury incidence compared with foam. True low-air-loss capability can be considered when heat and moisture at the skin–surface interface contribute to risk.
Neither replaces individualized repositioning and 24-hour positioning.
References
- Chan B, Ieraci L, Mitsakakis N, Pham B, Krahn M. Net costs of hospital-acquired and pre-admission pressure ulcers among older people hospitalised in Ontario. J Wound Care. 2013;22(7):341–346.
- Canadian Patient Safety Institute & HIROC. Never Events for Hospital Care in Canada. 2015. (CPSI is now Healthcare Excellence Canada.)
- Yap TL, Horn SD, Sharkey PD, et al. Effect of Varying Repositioning Frequency on Pressure Injury Prevention in Nursing Home Residents: TEAM-UP Trial Results. Adv Skin Wound Care. 2022;35(6):315–325.
- Vu T, Askin N. Therapeutic Support for Pressure Injuries. CADTH Health Technology Review RC1450. Can J Health Technol. 2022;2(9).
- Houghton PE, Campbell KE, CPG Panel. Canadian Best Practice Guidelines for the Prevention and Management of Pressure Ulcers in People with Spinal Cord Injury. Ontario Neurotrauma Foundation; 2013.
- Saskatchewan Health Authority. Support Surface Selection Algorithm. CS-A-0018.
- Registered Nurses' Association of Ontario. Pressure Injury Management: Risk Assessment, Prevention and Treatment. 4th ed. RNAO; 2024.
- Padula WV, et al. Estimating the value of repositioning timing to streamline pressure injury prevention efforts in nursing homes: a cost-effectiveness analysis of the TEAM-UP clinical trial. Int Wound J. 2024;21(1):e14452.
- European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, Pan Pacific Pressure Injury Alliance. Full Body Support Surfaces. In: Prevention and Treatment of Pressure Ulcers/Injuries: International Clinical Practice Guideline. 4th ed.; chapter version dated 20 May 2026. internationalguideline.com.
- 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). doi:10.3310/hta23520.
- 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.
- National Pressure Injury Advisory Panel, Support Surface Standards Initiative. Low Air Loss Terminology Position Statement. NPIAP; 2024.
- 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.
- National Pressure Injury Advisory Panel, Support Surface Standards Initiative. Terms and Definitions Related to Support Surfaces. NPIAP; 2024.
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.