Last reviewed: September 1, 2026
Pressure injuries remain one of the most preventable complications in Canadian long-term care.
$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]
“Stage 3 and 4 hospital-acquired pressure injuries — "Never Events."”
Never Events for Hospital Care in Canada · CPSI / HIROC [2]
TEAM-UP Trial · 2022
Foam is the foundation — appropriately so.
0.0%
New pressure injury incidence
Among residents without existing pressure injuries and not at severe risk (Braden ≥10), on viable 7-inch high-density foam, across 2-, 3-, and 4-hour repositioning intervals — a 4-week study window in nine U.S. nursing homes.
Yap et al., 2022 · Advances in Skin & Wound Care [3]
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 directs reassessment when clinical needs exceed what a reactive surface provides. [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.
Three limits of foam-only surfaces
But foam has limits.
01 · Immobility
It does not actively redistribute pressure.
If a resident cannot reposition independently, foam cannot compensate. The surface is reactive — not active.
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 cannot address microclimate.
For residents with incontinence, diaphoresis, or heavy wound exudate, foam alone cannot manage heat and moisture at the skin interface.
At the bedside
When to reassess the surface.
- 01The resident cannot reposition independently.
- 02The resident cannot be positioned off an area of concern.
- 03Skin or wound status is deteriorating despite an individualized prevention plan.
- 04Pressure injuries are present on multiple turning surfaces.
- 05The surface is bottoming out, or its performance is in doubt.
- 06Significant perspiration, incontinence or exudate burden is not contained by dressings or absorptive products.
- 07Consistent 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.
CADTH Health Technology Review · 2022
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.
Saskatchewan Health Authority · CS-A-0018
For residents with moisture burden.
“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]
TEAM-UP economic analysis · Padula et al., 2024
Repositioning intervals change the nursing-time math.
$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 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.
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. Prevention and Treatment of Pressure Ulcers/Injuries: International Clinical Practice Guideline. 4th ed. (staged online release; support surface chapters updated 2026). internationalguideline.com.
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.