Last reviewed: September 24, 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]
A 30-second read
Clinical takeaways
SS12: Good practice statement
Is the current foam surface meeting the resident's needs?
Re-evaluate it after an immobility-related pressure injury. Review repositioning, then consider a change if the resident cannot be positioned off the injury, has injuries on two or more areas used for positioning, is uncomfortable or bottoming out, or the injury is failing to heal despite a comprehensive plan and optimal wound care. [9]
SS3: Strong recommendation · Low-certainty evidence
Pressure-redistribution foam for residents at risk
SS3 compares pressure-redistribution foam with foam lacking those properties; it does not compare foam with powered surfaces. Alternating pressure or reactive air is usually reserved for residents at higher risk or with deteriorating skin or clinical condition. [9]
Randomized prevention trial
Alternating pressure versus high-specification foam
In acutely ill, high-risk UK inpatients (not LTC residents), the primary analysis showed no statistically significant difference in new Category 2 or worse injuries; a sensitivity analysis (up to 60 days) found significantly fewer people developed one on alternating pressure. [10]
For Directors of Care and purchasers: does your equipment plan allow timely access to a different surface when needs change?
Foam’s role · TEAM-UP Trial · 2022
Foam is the foundation — appropriately so.
- SS3: Strong recommendation · Low-certainty evidence
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 provides no powered airflow for microclimate management.
For residents with incontinence, diaphoresis, or heavy wound exudate not contained by dressings or absorptive products, 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). [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%
Sensitivity analysis (up to 60 days), not the primary endpoint · participants with a new Category 2 or worse pressure injury · 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
- For the primary endpoint — a new Category 2 or worse injury by the 30-day post-treatment follow-up (up to 90 days) — the difference was not statistically significant (6.9% vs 8.9%; HR 0.76, 95% CI 0.56–1.04; p = 0.089). In the treatment-phase sensitivity analysis (randomization to the end of the treatment phase, maximum 60 days; intention-to-treat), significantly fewer participants allocated alternating pressure developed a new injury (5.2% vs 7.8%; HR 0.66, 95% CI 0.46–0.93; p = 0.018): one fewer person with a new injury for every 38 allocated.
- Limitations
- The favourable result comes from a sensitivity analysis; the authors describe a small treatment-phase benefit that diminished over time. Acutely ill adult inpatients, not long-term care residents.
Nixon et al., 2019 · Health Technology Assessment [10]
In an exploratory analysis, the participants who appeared to benefit most from alternating pressure were those who were completely immobile, had altered skin or a Stage 1 (Category 1) injury at baseline, had a nutritional problem, or lacked capacity — some of the same findings that prompt a surface reassessment at the bedside. [10]
Heat and moisture · 2026 International Guideline · McNichol et al., 2020
For residents with moisture burden.
- SS11: Conditional recommendation · Very-low-certainty evidence
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” (SS11). [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.”
Choosing a support surface for pressure injury prevention and treatment
McNichol, Mackey, Watts & Zuecca · Nursing · 2020 [6]
The 2024 RNAO guideline (4th ed.) states that the “choice of support surface should be individualized”; it makes no recommendation for or against powered surfaces and lists considerations specific to them. 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.
CA$44K–$90K
Net hospitalization cost · per hospital-acquired Stage 2–4 pressure injury
Among older inpatients in an Ontario acute-care costing study (Canadian dollars; 2002–2006 case-costing data). 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]
US$12K–$18K
Lower modelled cost · per resident · per year (2020 US dollars)
Modelled savings of about US$12,146 (3-hour) and US$17,756 (4-hour) per resident versus 2-hour repositioning, from a one-year U.S. health-sector cost-effectiveness model built on TEAM-UP trial data (nursing home residents on high-density foam). The trial observed no significant difference in pressure injury rates; in the model, the savings came with slightly lower quality-adjusted life-years (0.18 and 0.26 fewer per resident). The authors attribute the savings to lower nursing-time costs and note that residents at high risk may need shorter intervals.
Padula et al., 2024 [8]
This is not a small number. At facility scale, it represents a meaningful amount of nursing time that could be reallocated toward higher-acuity care priorities — wound assessment, care planning, and the complex residents who need the most.
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 (one UK trial in acutely ill, high-risk adult inpatients), 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 in the within-trial analysis, though the trial authors judged the result not robust. [10][11]
The relevance for Canadian LTC
These modelled savings relate to repositioning schedules on high-density foam, not switching to a powered surface. Repositioning intervals remain individualized to the resident’s needs and response.
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.
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.
- McNichol L, Mackey D, Watts C, Zuecca N. Choosing a support surface for pressure injury prevention and treatment. Nursing. 2020;50(2):41–44. doi:10.1097/01.NURSE.0000651620.87023.d5. pmc.ncbi.nlm.nih.gov/articles/PMC7329246.
- Registered Nurses' Association of Ontario. Pressure Injury Management: Risk Assessment, Prevention and Treatment. 4th ed. RNAO; 2024 (2025 web update). pp. 53–59.
- 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(3):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.