Last reviewed: September 25, 2026
The bedside question
When a pressure injury is not healing, should the support surface be reassessed?
A resident has an individualized repositioning plan, but an existing pressure injury is not healing or is deteriorating. Reassess the whole care plan, including whether the current support surface meets the resident’s needs. [1][2]
A 30-second read
Clinical takeaways
SS12 and its implementation considerations
When healing stalls, reassess the surface.
Review and adjust repositioning, then consider changing the surface when, for example, an injury fails to heal despite comprehensive management and optimal topical wound care, cannot be offloaded, or the current surface is uncomfortable or bottoms out. [1]
SS13 / SS15: Conditional recommendations · Very-low-certainty evidence
Include powered options in the assessment.
For Stage 2–4 and unstageable injuries, the guideline’s suggestions include pressure-redistribution foam or alternating pressure air, and separately low air loss. Selection remains individualized. [1]
International Guideline · 2026 / Canadian Best Practice Guidelines · 2013
In the guidelines’ own words.
“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, thus reducing further ischemia or deformation-induced PIs.”
EPUAP / NPIAP / PPPIA International Guideline, 4th ed. · Full Body Support Surfaces · text accompanying SS12 (good practice statement), p. 14 · 2026 [1]
“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.”
Houghton, Campbell & CPG Panel · Ontario Neurotrauma Foundation · Pressure Ulcers in People with SCI · Rec. 5.14, p. 101 [4]
These guidelines were written for people with spinal cord injury; this recommendation is graded Level IV (expert committee reports or opinion). As in the International Guideline, the decision follows individual clinical assessment and reassessment, not stage alone.
Drawn from the International Guideline (2026)
Four factors to address in the stalled pressure injury, alongside wound care, nutrition and ongoing reassessment.
01
Repositioning
Individualized schedule and technique, matched to the resident’s mobility, skin and tissue tolerance, and clinical condition. [2]
03
Shear reduction
At the skin–surface interface and in deeper tissue, for example when the resident slides down the bed with the head of bed raised. [2][3]
04
Microclimate management
The support surface’s effect on temperature and humidity/moisture at the skin interface. [1]
Clinical factors that may prompt surface reassessment
Stage alone does not select the surface. The individual assessment does.
| Clinical picture | What the evidence says | Source |
|---|---|---|
| At risk (prevention): no current pressure injury, not at severe risk | The guideline recommends a pressure redistribution foam (reactive) surface for individuals at risk (SS3; strong recommendation, low certainty of evidence). TEAM-UP adds nursing-home prevention context (see below). | Guideline SS3 [1] · TEAM-UP [5] |
| At risk (prevention): higher risk, or deteriorating skin or clinical condition | The guideline suggests either alternating pressure air or pressure redistribution foam for individuals at risk (SS6; conditional recommendation, low certainty of evidence). Its evidence discussion for SS7 notes that foam is often adequate for many individuals at risk, while alternating pressure (active) air or air (reactive) surfaces are “usually reserved for individuals at higher risk or deteriorating skin condition or clinical condition.” | Guideline SS6, SS7 [1] |
| At risk (prevention): heat and moisture at the skin–surface interface contributing to risk | The guideline suggests low air loss could be used for individuals at risk, “especially when moisture and heat at the skin-surface interface are contributing factors” (SS11; conditional recommendation, very low certainty of evidence). McNichol and colleagues note it “may be indicated” for a diaphoretic resident, or for copious wound drainage or incontinence not contained by dressings or absorptive products. The guideline also notes that such a surface is not required to manage moisture from heavily exuding wounds or incontinence. | Guideline SS11 [1] · McNichol 2020 [3] |
| Existing injury: any immobility-related pressure injury, including Stage 1 | Re-evaluating the surface is good practice; at a minimum, an individual with a pressure injury requires a pressure redistribution foam (reactive) support surface (SS12; good practice statement). The guideline advises reviewing and adjusting the repositioning regimen before considering a surface change. | Guideline SS12 [1] |
| Existing injury: Stage 2–4 or unstageable | The guideline’s suggestions include either pressure redistribution foam or alternating pressure air (SS13) and, separately, low air loss (SS15). Both are conditional recommendations with very low certainty of evidence. | Guideline SS13, SS15 [1] |
| Existing injury: not healing despite a comprehensive plan and optimal topical wound care; cannot be positioned off the injury; injuries on two or more anatomical locations used for positioning; uncomfortable or bottoming out | The guideline lists each as a reason to consider changing the support surface (SS12 implementation considerations). The Canadian SCI guideline gives similar triggers for an active support surface (quoted above; Level IV). | Guideline SS12 [1] · SCI Rec. 5.14 [4] |
Selection follows the individual assessment: overall risk, skin and tissue response, independence, mobility and activity needs, posture and sleeping position, need for microclimate management and shear reduction, and preferences and care goals (SS4; good practice statement). [1] No row is an automatic surface rule. Staging follows NPIAP terminology (Stage 1–4); the International Guideline writes Category/Stage II–IV.
Comparative evidence is strongest for prevention. For healing outcomes, CADTH (2022) found it unclear whether surface types differ significantly, [6] and the guideline’s treatment suggestions (SS13, SS15) are conditional, with very low certainty of evidence. [1] The clinical picture — mobility, moisture, microclimate, offloading — drives the decision, not stage alone. This table is a reassessment aid, not a prescription; no support surface replaces individualized repositioning, skin assessment, wound care, nutrition and ongoing monitoring.
TEAM-UP Trial · 2022 · Prevention context
Viable foam with consistent repositioning — a prevention finding, when the clinical picture fits.
0.0%
New pressure injury incidence during the 4-week intervention · vs 5.24% annual incidence in the prior 12 months
Among residents without existing pressure injuries and not at severe risk (Braden ≥10), across sensor-cued 2-, 3-, and 4-hour repositioning intervals on viable 7-inch high-density foam, in nine U.S. nursing homes. A pre-post comparison; a causal link between repositioning intervals and outcome was not established.
Yap et al., Advances in Skin & Wound Care, 2022 [5]
In this population, viable high-density foam with consistent, cued repositioning is supported by evidence for prevention. [5]
This prevention study does not establish repositioning intervals for residents with existing pressure injuries, [5] and for individuals at risk of pressure injuries the 2026 guideline suggests not routinely extending repositioning intervals to four, five or six hours (R8; conditional recommendation, very low certainty of evidence). [2] Repositioning schedules remain individualized. [2]
Microclimate
Heat and moisture at the skin — one factor in the reassessment.
“Excessively moist, warm skin can increase the risk of skin breakdown,” McNichol and colleagues note, and support surfaces must be used alongside interventions such as nutritional support, microclimate (moisture and heat) management and heel offloading. [3]
NPIAP’s guidance on interpreting support-surface test standards links this risk to how a surface performs. Low moisture removal or a higher steady-state humidity at the interface “can result in increased moisture at the patient and support surface interface which may contribute to moisture associated skin damage,” while a higher interface temperature “may lead to an increase in risk for pressure injury.” [7] Low air loss is 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.” [8]
Randomized trial · JAMA 1993
The trial behind the low-air-loss healing suggestion.
The single randomized trial behind the guideline’s conditional suggestion (SS15) was run in nursing homes. [1] Eighty-four residents with trunk or trochanter pressure injuries (Shea stage 2 or worse) were assigned to a low-air-loss bed or a 10-cm convoluted foam mattress laid over a regular hospital mattress, and followed for a median of 37.5 days. [9][10] The median wound-area healing rate was more than threefold higher on low air loss (9.0 vs 2.5 mm²/day; P = .0002), and was also higher within both the deep and the superficial subgroups. [9][10] This figure measures the rate of reduction in wound area — not the proportion of injuries that healed completely.
The technology was the low-air-loss bed system studied in the trial published in 1993, not a current mattress replacement. [10] For complete healing, the guideline reports no statistically significant difference in this trial and rates the certainty of the evidence as very low (SS15). [1] The trial speaks to existing injuries (SS15) — not specifically to stalled wounds or the moisture picture — and does not rank current mattresses. [1]
In practice
Assessment and reassessment drive surface selection. Changing the surface is one response when reassessment shows the current plan is not enough. [1]
When developing the repositioning regimen, the International Guideline advises considering the resident’s positioning needs over a 24-hour period, including where and when they sleep, lie and sit. [2]
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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). SS3, SS4, SS6, SS7, SS11, SS12, SS13, SS15; pp. 1, 5–6, 8–9, 13–16. https://www.internationalguideline.com/surfaces
- National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Repositioning and Mobilization. In: Haesler E, ed. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. 4th ed. 2026. Version date 14 May 2026. R2, R3, R4, R5, R8, R11; pp. 1–2, 4–5, 8, 13. https://www.internationalguideline.com/repositioning
- 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.
- 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.
- 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).
- National Pressure Injury Advisory Panel, Support Surface Standards Initiative. Guidance on Interpretation of Performance Standards for Support Surfaces, version 2.0. n.d. (PDF unpaginated; cited by PDF page). https://npiap.com/page/S3I
- National Pressure Injury Advisory Panel, Support Surface Standards Initiative. Low Air Loss Terminology Position Statement. NPIAP; 2024 (PDF unpaginated; cited by PDF page). https://npiap.com/page/S3I
- 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 10).
- 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/
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.