What is the role of support surfaces in the care of pressure ulcers?

Updated: Apr 24, 2020
  • Author: Brian J Daley, MD, MBA, FACS, FCCP, CNSC; Chief Editor: Zubin J Panthaki, MD, CM, FACS, FRCSC  more...
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Support surfaces are further discussed as follows:

  • Federal regulations (Medicare Bulletin 405) dictate that patients with bedsores or those who are at risk for bedsores must be placed on an appropriate support surface.

  • Federally mandated standards of care dictate what support surfaces are allowable and provide for both civil and criminal penalties for health care entities that fail to comply.

  • Proper prevention and management of pressure ulcers in health care facilities is mandated by federal regulations (Ch IV § 483.25 (c)(1)&(2), 10/1/95), which state, "Based on the comprehensive assessment of a resident, the facility must ensure that (1) a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable, and (2) a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing."

  • A class I support surface is a simple pressure pad device that is required as follows:

    • For patients who cannot independently change their body position to effectively alleviate pressure

    • For patients who have any stage of pressure ulcer on the trunk or pelvis, plus impaired nutritional status, fecal or urinary incontinence, altered sensory perception, or compromised circulatory status

  • A class II support surface is a pressure-relieving device that reduces pressure over bony prominences to less than 32 mm Hg and that does so for a sustained period. A class II support surface is required as follows:

    • For patients who have multiple pressure ulcers on the trunk or pelvis that has not improved despite a comprehensive treatment, including a class I support surface for a stage II, III, or IV pressure ulcer for at least 1 month

    • For patients who have large or multiple stage III or IV pressure ulcers on the trunk or pelvis

    • For patients who have had a myocutaneous flap or skin graft procedure for a pressure ulcer on the trunk or pelvis within the past 60 days and have been on a class II or III support surface immediately before a recent discharge from a hospital or nursing facility within the past 30 days

  • A class III support surface is an advanced pressure-relieving device. A class III support surface, that is, an air-fluidized bed, may be used only for failure of a comprehensive conservative treatment plan after 30 days. (Note that an air-fluidized bed is contraindicated for any patient with associated severe pulmonary compromise because the absence of firm back support makes coughing ineffective, and the dry air thickens pulmonary secretions.) Such a conservative treatment program includes the following:

    • Education of the patient and the caregiver. A patient information page regarding pressure ulcers is available. [38]

    • Assessment by a licensed health care practitioner, at least weekly

    • Appropriate turning and positioning

    • Use of a class II support surface

    • Appropriate wound care

    • Appropriate management of incontinence

    • Appropriate nutritional management

Table 3. Support Surfaces (Open Table in a new window)







Pressure-relieving pad or mat

3- to 5-inch foam mattress, gel overlay, egg-crate mattress



Powered air* overlay for mattress with low air loss feature; nonpowered advanced pressure-reducing mattress replacement or powered air* flotation bed with or without low air loss feature

Roho dry floatation mattress system, Pegasus Renaissance mattress


Air fluidized

Flotation by filtered air* flow pumped through porcelain beads

Clinitron bed

*Long-term use of powered air devices is relatively contraindicated for patients with chronic obstructive lung disease, such as chronic bronchitis, emphysema, and asthma.

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