Last reviewed: September 3, 2026
The bedside question
If every two-hour repositioning is not working, what do you do?
One of the most common questions in long-term care wound management — and one of the hardest to answer at the bedside.
A resident on a foam surface. On an individualized, evidence-based repositioning schedule. With a pressure injury that will not close, or a Stage 2 progressing toward Stage 3.
The care plan is compliant. The clinical outcome is not.
TEAM-UP Trial · 2022
Foam works — when the clinical picture fits.
0.0%
New pressure injury incidence · compared with 5.24% at baseline
Among residents without existing pressure injuries and not at severe risk (Braden ≥10), across 2-, 3-, and 4-hour repositioning intervals on viable 7-inch high-density foam — a 4-week study window in nine U.S. nursing homes.
Yap et al., Advances in Skin & Wound Care, 2022 [1]
For low-to-moderate-risk residents, foam combined with structured repositioning is not just acceptable — it is evidence-based.
But this is a prevention finding, in residents matched to the protocol. It is not a finding about treating a Stage 3 pressure injury that will not heal. Conflating the two is among the most common errors in facility-level surface policy.
EPUAP / NPIAP / PPPIA International Guideline
Four interventions. For the stalled pressure injury, all four must be addressed — simultaneously.
01
Repositioning
Schedule and technique matched to resident mobility and skin integrity.
02
Pressure redistribution
Immersion and envelopment through the support surface.
03
Shear reduction
At the skin–surface interface and in deeper tissue when the head of bed is raised.
04
Microclimate management
Heat and moisture at the skin interface — temperature, humidity, airflow. The most commonly overlooked variable.
Clinical factors that may prompt surface reassessment
Stage alone does not indicate a powered surface. Mobility and moisture do.
| Clinical picture | Stage | Surface category |
|---|---|---|
| Low–moderate risk, preserved mobility, intact skin | At risk · 1 | High-density foam (reactive) |
| Immobile, low moisture burden | 1–2 | Alternating pressure (AP) |
| Significant moisture burden — diaphoresis, incontinence, heavy exudate | 1–4 | True low air loss (TLAL) |
| Stalled healing · complex pressure injuries · heavy exudate · infection · poor nutrition · multiple turning surfaces · post flap/graft (≤60 d) | 3–4 | Combination therapy (AP + TLAL) |
| Rotation indicated — pulmonary compromise, post-surgical, stroke | 1–4 | TLAL with lateral rotation |
Adapted from Saskatchewan Health Authority Support Surface Selection Algorithm (CS-A-0018) [3]; CADTH RC1450 (2022) [4]; EPUAP/NPIAP/Pan Pacific (2019) [2]. Staging follows NPIAP terminology — Stage (Arabic numerals); older documents write Category.
A note on certainty: comparative evidence is strongest for prevention. For treatment — healing outcomes — CADTH (2022) found it unclear whether surface types differ significantly, and the current International Guideline (4th ed., 2026) conditionally suggests either foam or alternating pressure for Stage 2–4 injuries, with very low certainty, and separately suggests low air loss full body support surfaces “for individuals with Category/Stage II–IV and unstageable pressure injuries” (SS15; conditional recommendation, very low certainty of evidence). [4][7] The decision is driven by the clinical picture — mobility, moisture, microclimate, offloading — not by stage. This table is a reassessment aid, not a prescription; no support surface replaces individualized repositioning, skin assessment, wound care, nutrition and ongoing monitoring.
International Guideline · 2026 / Canadian Best Practice Guidelines · 2013
What the guidelines say.
“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.”
EPUAP / NPIAP / PPPIA International Guideline, 4th ed. · Full Body Support Surfaces, SS12 implementation guidance · 2026 [7]
“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, if new ulcers develop.”
Houghton, Campbell & CPG Panel · Ontario Neurotrauma Foundation · Pressure Ulcers in People with SCI [5]
These guidelines were written for spinal cord injury care — among the most evidence-dense pressure injury literature. Their escalation triggers are widely used as practical bedside logic for stalled healing beyond SCI, applied through individual clinical assessment. Direct trial evidence in general LTC populations is more limited — which is exactly why reassessment, not stage alone, drives the decision.
Microclimate
The overlooked variable in the stalled pressure injury.
Inadequate microclimate management drives a cascade. Addressing pressure and repositioning without managing heat and moisture leaves the skin vulnerable at exactly the point treatment demands the most from it.
Low air loss is indicated for diaphoretic residents, or for wound drainage or incontinence not contained by dressings or absorptive products (Saskatchewan Health Authority, CS-A-0018). [3]
The mechanism is written into the support-surface test standards. 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.” Low air loss is the 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][9]
- 01Heat and moisture build at the skin interface.
- 02Skin maceration follows.
- 03Friction at the skin–surface interface increases.
- 04Skin-stripping risk rises with each repositioning.
- 05Shear on deeper tissues elevates when the head of bed is raised.
Randomized trial · JAMA 1993
The one randomized trial of low air loss for healing.
The only randomized trial of low air loss for healing was run in nursing homes. 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 foam mattress until healed. The median healing rate was more than threefold higher on low air loss (9.0 vs 2.5 mm²/day; P = .0002), for deep and superficial wounds alike, and after adjusting for fecal continence, residents on low air loss remained 2.5 times more likely to heal in a given period. [10]
The technology was a 1993 bed system rather than a current mattress replacement, and later systematic reviews rate the complete-healing evidence as low certainty; the trial supports the clinical rationale for escalating to low air loss when healing stalls.
Full therapy range on one platform — AP, TLAL, combination, rotation.
Practical next steps
Ask about an OpalAir evaluation or trial with a complex resident, or request a clinical justification template to support a facility purchasing decision — through the education request form or contact@evergreenmedicalproducts.com.
Trials and evaluations are coordinated with your facility and, where applicable, your dealer.
The support surface manages the bed interface. Positioning supports extend the individualized plan across lying, seated and transitional positions — both belong in a 24-hour approach.
Assessment and reassessment are what drive surface selection. Escalation is how the care plan responds when reassessment shows it is not enough.
References
- 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.
- European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. 3rd ed. 2019.
- Saskatchewan Health Authority. Support Surface Selection Algorithm. CS-A-0018.
- 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.
- Registered Nurses' Association of Ontario. Pressure Injury Management: Risk Assessment, Prevention and Treatment. 4th ed. RNAO; 2024.
- 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.
- National Pressure Injury Advisory Panel, Support Surface Standards Initiative. Guidance on the Interpretation of Support Surface Performance Standards, version 2.0. NPIAP.
- National Pressure Injury Advisory Panel, Support Surface Standards Initiative. Low Air Loss Terminology Position Statement. NPIAP; 2024.
- 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.
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.