Full Body Support Surfaces for Prevention of Pressure Injuries (Part 1)
Published online: 25 February 2025
Suggested citation
National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Full Body Support Surfaces for Prevention of Pressure Injuries. In: Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline: Fourth Edition. Emily Haesler (Ed.). 2025. [cited: download date]. Available from: https://internationalguideline.com.
Introduction
Full body support surfaces are specialized mattresses, overlays and integrated systems that are designed to redistribute pressure, reduce friction and shear, and aid microclimate management, all factors that play a role in pressure injury development. (1)
Pressure redistribution is achieved through envelopment and immersion capabilities. Envelopment is the ability of the support surface to conform to the individual’s shape, and immersion is the ability of the individual to penetrate or sink into the support surface. Additionally, some support surfaces have characteristics through which they achieve microclimate management, which refers to control of the humidity/moisture at the interface between the individual and the support surface. (1)
Support surfaces are categorized as active or reactive. An active support surface is a powered support surface with the capability to change its pressure redistribution properties independent of applied load.(1) An alternating pressure support surface is an example of an active surface. A reactive support surface is a powered or non-powered support surface with the capability to change its pressure redistribution properties only in response to an applied load (e.g., an individual lying on the surface). Examples of reactive support surfaces are pressure redistribution foam, static air mattresses and low air loss support surfaces. (1)
The Support Surface Standard Initiative (S3I) of the National Pressure Injury Advisory Panel (NPIAP), (1) and the Rehabilitation Engineering and Assistive Technology Society of North America/American National Standards (RESNA/ANSI) have developed terminology, test methods and reporting standards for support surfaces. The S3I suggest terminology for use to promote a common language when referring to performance characteristics, design features, components and categories. Table 1 provides an abridged framework from S3I outlining the currently endorsed vocabulary. The full document also includes general terms and engineering terms associated with support surfaces.
Standardized testing of support surfaces is important, because it provides objective data that can assist clinicians to determine whether the characteristics of the support surface are appropriate for the individual’s needs and to compare performance between products. RESNA/ANSI has endorsed and published a volume of standards (SS-1) that define vocabulary and test methods for pressure redistributing and microclimate management performance characteristics. In other jurisdictions, similar national standards for support surfaces and assistive devices detail the general requirements (e.g., European Parliament, Australian Rehabilitation and Assistive Technology Association [ARATA], etc.).
Selecting a Full Body Support Surface
SS1: Good Practice Statement
It is good practice for organizations to maintain an inventory of, or access to, a range of full body support surfaces appropriate to the clinical context. The inventory should be maintained, stored and used in accordance with manufacturer recommendations.
More information
Clinical question: What are considerations in ensuring availability and safe use of full body support surfaces for individuals at risk of pressure injuries?
Implementation considerations
Consider the individual’s goals of care and priorities when developing an individualized repositioning regimen. Work with the individual, their informal carer and the collaborative healthcare team to develop a repositioning regimen that meets the individual’s needs.
Consider an individual’s positioning needs over a 24-hour period when developing a repositioning regimen. This should include where and when they sleep, lie and sit. Individuals who have limited mobility may also require specialist advice regarding full body support surfaces and other equipment they use, as well as assessment and planning that addresses body symmetry and postural support. Involve the collaborative healthcare team (e.g., physiotherapist, physical therapist, occupational therapist, seating specialist, etc.), particularly for individuals at long term risk of PIs. (7)
Check all pressure points when repositioning the individual to ensure that pressure has been adequately offloaded (i.e., Check that recently loaded pressure points are relieved of sustained pressure). Areas such as the gluteal cleft, elbows, malleolus and wrists are vulnerable to PIs but are easily overlooked.
Assess the individual’s pain and comfort level before and after repositioning. (8, 9, 10) Evaluate the need for analgesia prior to repositioning. When required, pre-medicate prior to assisting the individual with repositioning.
Assess the individual’s full body when repositioning. Evaluate body alignment and posture to maximize comfort, support and pressure offloading. Use additional repositioning devices to provide comfort as required.
Use positioning devices. These devices can assist in maintaining positioning, be used to elevate parts of the body off the support surface, and can promote body symmetry, posture and comfort. When placing a positioning device, take care that it is not positioned in a way that applies pressure to an anatomical area that is intended to be relieved of pressure (e.g., do not position a pillow directly against the sacrum when positioning the individual in a lateral position). Consider using specialist repositioning devices to support the individual’s specific needs/body shape (e.g. fluidized positioners that can be shaped). (11, 12, 13, 14)
Check that no objects (e.g., mobile phone, cutlery, etc.) or medical devices are underneath the individual. When repositioning individuals with medical devices, ensure the device is also appropriately repositioned to prevent device-related pressure and friction. Further implementation considerations are available in the guideline section Preventing Device Related Pressure Injuries.
Additional implementation considerations for special populations
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Encourage the individual to self-reposition as often as possible. Informal carers might be involved by reminding the individual to regularly reposition.
Assess and monitor individuals who are self-repositioning to ensure their self-repositioning techniques (e.g., bed movement) effectively offload pressure points and avoid shear and friction. For example, observe the individual self-turning to ensure that they are effectively offloading the sacrococcygeal region and heels.
Assess the individual’s experience of pain, and if required implement a pain management plan. Uncontrolled pain can be a barrier to regular repositioning.
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Ensure that equipment used in repositioning neonates and children is appropriate for use in pediatric populations.
Be aware that weight distribution varies as children grow. Infants and toddlers have proportionally heavier heads and are at increased risk of occipital PI. Body weight distribution slowly shifts toward adult proportions as the child grows.
Pay particular attention to the head of infants and neonates as this is one of the most common anatomical locations in which they experience PIs. Frequently reposition the head where possible and safe (in neonates, discuss safe head positioning with the medical team(15)). Use regular repositioning and pressure redistribution devices (e.g., fluidized positioners) to offload pressure from the occipital ridge.
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Use purposeful reminders to reinforce regular repositioning for individuals who can self-reposition.
Use person-centred care approaches (e.g. distraction, music therapy, etc.) and communication techniques to facilitate acceptance of repositioning and maintenance of pressure-relieving positions.
Consider using movement therapy as an outlet for excess energy to reduce high frequency movement associated with agitation that could introduce shear, increasing the risk of skin and tissues damage.
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Discuss goals of care and prioritize patient comfort.(16, 17)
Ask the individual and their informal carer about positions and equipment that best promote their comfort.(16)
Inspect the skin at every opportunity and take additional care to avoid skin injury. Skin becomes increasingly fragile at the end-of-life and may be more prone to injury.(16)
Implement smaller, incremental body repositioning (micromovements), and regularly reposition the extremities and head if the individual at end-of-life cannot tolerate full body repositioning.
Address pain management requirements to facilitate repositioning with minimal discomfort. Pain may limit comfortable repositioning.(16)
Discuss choices about repositioning frequency intervals that are best suited to the goals of care and comfort needs of the individual. Provide them with knowledge about pressure injury risk incurred with less frequent repositioning so they can make informed choices.
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Encourage self-repositioning by scheduling repositioning into the daily routine where possible,(18) for example encouraging incidental movement or natural breaks in activities.
Supporting information
Individuals at risk of PIs have varying clinical needs, preferences and goals of care; therefore, the entity that that provide full body support surfaces should ensure there is access to different full body support surfaces with a range of performance characteristics and design features to address the various and diverse needs of individuals. Policies and procedures should be implemented to ensure that support surfaces provided by the entity meet the relevant ISO standards, are regularly maintained and used safely. Regular inspections should be undertaken to ensure support surfaces are safe for their intended use and within their functional life span. Surfaces and bed frames that do not have pressure redistribution performance characteristics or that require maintenance or that are beyond their functional lifespan should be removed from circulation.
SS2: Good Practice Statement
It is good practice to use a full body support surface or integrated bed system that appropriately accommodates the weight, height, size and body mass distribution of the individual.
More information
Clinical question: What are the general considerations when selecting a full body support surface for individuals at risk of pressure injuries?
Implementation considerations
Follow the support surface selection protocol of the health service/organization where available.
Follow the manufacturer’s recommendation for the use of the full body surfaces, including recommendations for the individual’s weight, height and dimensions.
Ensure that the full body support surface is sufficiently wide to allow the individual to safely turn/be repositioned from one side to the other. Be aware of the manual handling risk to the carer (i.e., staff leaning/excessive reaching to care for an individual) when using an extended width full body support surface.
Ensure there is adequate clearance between the individual and bed rails/sides to avoid device related pressure injuries.
Check that taller individuals have adequate clearance between their feet and the footboard.
Additional implementation considerations for special populations
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Only use the support surface that is fitted in the isolette for neonates (i.e. do not add additional full body support surfaces). Specialist positioning devices might be used for some neonates at high risk of PIs (e.g. micro-premature) for repositioning the head.
Ensure that the support surface is age appropriate. Support surfaces that are not appropriate for the child’s age, weight, dimensions and body proportions may be unsafe and may increase the risk of PIs (e.g. sectioned mattresses).
Ensure mattresses/overlays are correctly fitted. There is a risk of entrapment when using a poorly fitted full body support surface.
Supporting information
A full body support surface should appropriately accommodate the individual’s size and distribution of mass to ensure its performance characteristics function as intended. A full body support surface should provide adequate width to facilitate repositioning and/or bed mobility, and to promote safety. Consider the individual’s age, and body habitus when selecting a full body support surface within manufacturers’ recommendations.
More information
SS3: Recommendation
We recommend using a pressure redistribution foam (reactive) full body support surface for individuals at risk of pressure injuries.
Strong recommendation; low certainty of evidence
Clinical question: Should pressure redistribution foam (reactive) full body support surfaces versus a non-pressure redistribution foam support surfaces be used to prevent PI occurrence for individuals at risk?
Implementation considerations
Identify the types of foam surfaces (pressure redistribution versus non-pressure redistribution) available in the current clinical setting. Staff who are responsible for selecting support surfaces should have a strong understanding of the types of foam support surfaces available in a health service and whether they meet the standards for pressure redistribution.
Ensure that devices (e.g., interface mapping systems, incontinence aids) and bed linen (e.g., continence management, sheets) that are used between the individual and the support surface do not interfere with the function of the support surface. Ensure linen is applied without any wrinkles. Avoid multiple linen layers under the individual.
Additional implementation considerations for special populations
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Use a pressure redistribution foam support surface for children and adolescents at high risk of PIs. Specialized repositioning devices designed for neonates and children are another option that have been associated with reduction in interface pressure; (14) it is uncertain if this translates to reduced PI occurrence.
Evidence Summary
A meta-analysis that included six RCTs (6, 7, 8, 9, 10, 11) showed that pressure redistribution foam (reactive) full body support surfaces were associated with a non-significant lower rate of PIs (relative risk [RR] 0.36, 95% confidence interval [CI] 0.19 to 0.65, p = 0.14) compared with foam mattresses without pressure redistribution characteristics. This translated to 106 fewer per 1,000 individuals experiencing a PI (from 135 fewer individuals to 58 fewer individuals) when a pressure-redistribution foam (reactive) full body support surface is used. However, the evidence was of low certainty and was downgraded for risk of bias and inconsistency. The studies explored a range of pressure redistribution foam (reactive) mattresses[*] (circa 1994 to 2003), all of which were and compared to a “standard” polypropylene/vinyl hospital mattress. In most clinical settings, a pressure redistribution foam (reactive) full body support surface is acceptable and feasible to use, although access varies in some low resource settings. Modelling conducted in aged care (12) and emergency care (13) demonstrated that changing from foam mattresses with no pressure redistribution properties to pressure-redistribution foam (reactive) full body support surfaces has a high likelihood of being cost effective. The Guideline Governance Group made a strong recommendation despite low certainty of evidence because the risk of harm in not using a full body support surface with pressure redistribution features for individuals at risk of PIs is very high. The current standard of practice requires a pressure redistribution full body support surface for prevention of PIs; further research on this topic using stronger research designs is not appropriate.
In the Guideline Governance Group’s expert opinion, a pressure redistribution foam (reactive) full body support surface should be the first support surface of choice for individuals at risk of PIs.
[*] Support surfaces reported throughout all the research were considered in this Guideline based on their categorization by the researchers (at the time the research was undertaken). Where available, the product name and characteristics were included in the data extraction tables. Product names/technology may have changed. Due to advances in technology, currently available full body support surfaces in the same category may have different performance characteristics.
Data tables (Downloads)
Process document (includes meta-analysis)
Data extraction tables (coming soon)
Full evidence discussion (coming soon)
Certainty of Evidence
| Certainty assessment | No of patients | Effect | Certainty |
Importance |
||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
No of studies |
Study design |
Risk of bias |
Inconsistency |
Indirectness |
Imprecision |
Other considerations |
pressure redistribution foam (reactive) surfaces |
standard mattress/ non-pressure redistribution foam (reactive) surface |
Relative (95% CI) |
Absolute (95% CI) |
||
| 6 | Randomized trials |
Very serious [a] |
Serious [b] | Not serious |
Not serious |
none | 102/1296 (7.9%) |
138/831 (16.6%) |
RR 0.36 (0.19 to 0.65) |
106 fewer per 1,000 (from 135 fewer to 58 fewer) |
Low |
CRITICAL |
[a] Five of the studies had high or unclear risk of performance and detection bias.
[b] serious heterogeneity
Evidence to Decision Framework
Problem:
Desirable Effects:
Undesirable Effects:
Certainty of Evidence:
Values:
Balance of Effects:
Resources Required:
Certainty of Evidence of Required Resources:
Summary of Judgements
Cost Effectiveness:
Inequity:
Acceptability:
Feasibility:
Yes
Large
Small
Low
No important uncertainty or variability
Probably favors the intervention
Varies
Very low
Probably favors the intervention
Varies
Probably yes
Yes
Changing from a Pressure Redistribution Foam (reactive) Full Body Support Surface
For a variety of clinical and practical reasons, a decision to change from/select an alternate full body support surface may be made. In general, different options should be considered when the individual has a moderate or high risk of PIs, and/or has previously experienced a PI on a pressure redistribution foam (reactive) full body support surface. In addition to pressure redistribution foam (reactive) full body support surfaces, the following surfaces provide pressure redistribution and have been shown to reduce PI incidence in relation to various comparators, including:
Alternating pressure air (active)
Air (reactive) (not including low air loss)
Medical grade sheepskin
Low air loss (reactive) with microclimate management
Air fluidized (reactive).
S3I defines microclimate management as "the impact of a support surface on the temperature and humidity/moisture in a specified location at the body interface". (1) Low air loss is defined 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. (1)
The term low air loss is consistent with the 2024 S3I definition and with the studies examining full body support surfaces with a low air loss design that were included in the data analysis for this guideline. Therefore, the term is used throughout this document. However, S3I discourages the use of the general term, low air loss. Clinicians are encouraged to use the results of standardized performance characteristic test data related to pressure redistribution and microclimate management to make an informed decision based on the risk factors of the individual when selecting a full body support surface, rather than relying on a specific design feature. See www.npiap.com for updates.
For recommendations on changing FROM a pressure redistribution foam (reactive) full body support surface TO A DIFFERENT full body support surface see Part 2 of this section: recommendations SS4 to SS11.
Support Surfaces in Specific Clinical Settings
SS12: Good Practice Statement
It is good practice to use a full body support surface with pressure redistribution features for medical procedures and for an individual at risk of pressure injuries in transit.
More information
Clinical question: What are the general considerations with respect to support surfaces for transit of an individual at risk of pressure injuries?
Supporting Information
Individuals are at risk of PIs when they are in contact with any support surface and have a degree of immobility or inactivity. This includes vehicle transportation, while waiting for a clinical review and/or admission in the emergency department, and while undergoing medical assessments and procedures. (44) Undertaking a comprehensive PI risk assessment during transit is often not possible, particularly in the emergency vehicle when the care team has competing priorities (e.g., respiratory and cardiac stabilization). Using a full body support surface as soon as possible in the care journey for individuals at PI risk is good practice.
SS13: Good Practice Statement
It is good practice to transfer the individual off a spinal hard board/backboard as soon as medically feasible after admission, in consultation with a qualified health professional.
More information
Clinical question: What are the general considerations with respect to support surfaces for transit of an individual with suspected spinal cord injury?
Supporting Information
Individuals with suspected spinal cord injury (SCI) are often managed prior to hospitalization with an extrication collar and long spine board or spinal backboard to restrict spinal motion. Restriction of spinal motion (particularly on a long spine board) is associated with increased adverse events, including pressure injuries.(45) Transferring the individual from a long spine board/backboard to a pressure redistribution support surface as soon as clinically feasible is good practice.
Resources
Table 1: Extract of S3I terminology (1)
| Support surface category | Component/material | Design features | Performance characteristics |
|---|---|---|---|
|
|
|
|
Table 2: Selected resources on standards tests for full body support surfaces
References
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