Pressure Relief Mattress & Bed Sore Prevention: Brantford Guide

8 min read

Understanding Pressure Injuries

How Pressure Injuries Develop

A pressure injury occurs when sustained pressure on an area of skin compresses the blood vessels, reducing or cutting off blood flow to the tissue. Without blood flow, the tissue does not receive oxygen and nutrients, and cellular waste builds up. If the pressure is not relieved, the tissue begins to break down.

Three factors combine to cause pressure injuries:

• Pressure: The primary cause. Body weight pressing skin against a surface compresses blood vessels. The highest-pressure areas are where bone is close to the skin surface (sacrum, heels, elbows, shoulder blades, back of the head)
• Shear: When layers of tissue slide against each other, such as when a person slides down in bed. Shear damages blood vessels beneath the skin even when surface pressure appears manageable
• Friction: Rubbing of the skin against a surface, which removes the outer protective layer and makes the skin more vulnerable to pressure damage

Pressure Injury Stages

The critical takeaway: stages 1 and 2 are where a consumer mattress makes the biggest difference. A quality pressure-redistributing mattress can prevent stage 1 injuries from developing and prevent stage 1 from progressing to stage 2. Stages 3 and 4 require medical-grade equipment and professional wound care.

Who Is at Risk

Pressure injuries can affect anyone who remains in one position for extended periods, but some people face significantly higher risk:

• Reduced mobility: People who cannot reposition themselves in bed independently due to paralysis, severe arthritis, post-surgical recovery, or advanced age
• Reduced sensation: People who cannot feel discomfort that would normally prompt repositioning (spinal cord injury, diabetic neuropathy, peripheral nerve damage)
• Poor nutrition: Inadequate protein, calorie, or micronutrient intake impairs skin integrity and wound healing. Malnutrition is one of the strongest risk factors for pressure injury development
• Moisture exposure: Incontinence, excessive perspiration, or wound drainage keeps skin damp, making it more vulnerable to breakdown
• Circulatory problems: Diabetes, peripheral vascular disease, and heart failure reduce blood flow to tissues, making them more susceptible to pressure damage
• Advanced age: Aging skin is thinner, less elastic, and heals more slowly. Older adults have reduced subcutaneous fat padding over bony prominences

Mattress Types for Pressure Relief

Reactive (Passive) Surfaces

Reactive surfaces conform to the body's shape, redistributing pressure across a larger surface area. They do not have moving parts or require power.

• High-specification foam: Multi-density foam with zoned construction. Higher-density foam supports the body while lower-density foam in pressure zones (shoulders, hips) allows greater immersion. The most cost-effective option for low to moderate risk individuals. Research shows these perform nearly as well as alternating pressure for most patients (Nixon et al., 2019)
• Viscoelastic (memory) foam: Conforms closely to body contours, distributing pressure across a large surface area. Effective for pressure redistribution but can retain heat and make repositioning more difficult. Best for people who do not need to reposition themselves independently
• Latex foam: Naturally responsive, provides pressure redistribution while maintaining enough resilience for repositioning. Cooler than memory foam. Good option for people who can still move somewhat independently
• Static air overlays: Air-filled cells that conform to body shape. Can be placed on top of an existing mattress. Provide good pressure redistribution. Evidence suggests they may reduce pressure ulcer risk compared to standard foam (Shi et al., 2021)

Active (Dynamic) Surfaces

Active surfaces use powered mechanisms to periodically change the pressure distribution. They require electricity and have moving components.

• Alternating pressure mattresses: Air cells inflate and deflate in alternating cycles, periodically relieving pressure on different body areas. Effective for high-risk patients but can disrupt sleep, cause nausea, and make some people feel unstable
• Low-air-loss mattresses: Provide a constant flow of air through small holes in the surface, helping manage moisture and reduce interface pressure. Used primarily in clinical settings for stage 3 and 4 injuries
• Air-fluidized surfaces: Microscopic silicone beads suspended by warm air flow, creating a fluid-like surface. The highest level of pressure redistribution available. Used exclusively for severe pressure injuries in clinical settings

What the Research Shows

The PRESSURE 2 trial, one of the largest randomized controlled trials comparing mattress types for pressure ulcer prevention, found that alternating pressure mattresses and high-specification foam mattresses produced similar pressure ulcer prevention outcomes in high-risk patients (Nixon et al., 2019). The study concluded that either surface type was appropriate for most at-risk patients.

A Cochrane review covering 32 studies and over 9,000 participants confirmed that the difference between alternating pressure and high-specification foam was small, with alternating pressure being more cost-effective in healthcare settings but high-specification foam being better tolerated by patients (Shi et al., 2021).

Selecting the Right Mattress by Risk Level

Low Risk (Mobile but Aging or Recovering)

People who can still reposition themselves but are spending more time in bed due to aging, temporary illness, or recovery from a minor procedure.

• Recommended: Quality consumer mattress with zoned support and a responsive comfort layer (latex or high-resilience foam). The mattress should provide enough pressure redistribution at the shoulders and hips without being so soft that repositioning becomes difficult
• Key features: Medium to medium-firm support, breathable cover, waterproof protector compatibility
• Budget: $800 to $1,500

Moderate Risk (Limited Mobility, Some Risk Factors)

People with reduced ability to reposition, one or more risk factors (age over 70, diabetes, mild circulatory issues), or early signs of skin redness over pressure points.

• Recommended: High-specification foam mattress with multi-density zoned construction, or a quality mattress plus a static air overlay. The comfort layer should provide measurable pressure redistribution at the sacrum and heels
• Key features: Zoned pressure relief, moisture-wicking cover, low-friction surface, compatible with incontinence protection
• Budget: $1,000 to $2,000

High Risk (Immobile, Multiple Risk Factors, Existing Breakdown)

People who cannot reposition independently, have multiple risk factors, or already have stage 1 or 2 pressure injuries.

• Recommended: Consult a healthcare provider (physician, wound care nurse, or occupational therapist) for a formal risk assessment and surface recommendation. An alternating pressure mattress or specialized medical surface may be appropriate
• Key features: Active pressure redistribution, moisture management, infection control compatible cover
• Note: Ontario Health at Home (formerly CCAC) may provide or fund specialized surfaces for eligible patients. Ask your healthcare provider about coverage

The SSKIN Prevention Framework

The mattress is one component of a comprehensive pressure injury prevention strategy. The SSKIN framework, widely used by Canadian healthcare organizations including the Registered Nurses' Association of Ontario (RNAO), provides a structured approach:

S: Surface

Select the appropriate support surface based on risk level. Ensure the mattress is in good condition with no sagging, bottoming-out, or worn areas. Replace mattresses that have lost their support properties. Use a mattress overlay if the current mattress does not provide adequate pressure redistribution.

S: Skin Inspection

Inspect skin over bony prominences daily, particularly the sacrum, heels, elbows, shoulder blades, and back of the head. Look for areas of redness that do not turn white when pressed (non-blanchable erythema). In darker skin tones, look for changes in colour, temperature, firmness, or moisture compared to surrounding areas.

K: Keep Moving

Reposition at minimum every 2 hours for people confined to bed. Use a 30-degree tilt rather than a full side-lying position to reduce pressure on the trochanter (hip bone). Use pillows between bony prominences (knees, ankles) to prevent friction. Encourage any movement the person can do independently.

I: Incontinence and Moisture

Keep skin clean and dry. Use moisture barrier products on areas exposed to incontinence. Change incontinence pads promptly. Use a breathable waterproof mattress protector that manages moisture without trapping heat against the skin.

N: Nutrition

Adequate protein intake is essential for maintaining skin integrity and wound healing. Ensure adequate hydration. Consider a nutritional assessment for anyone at moderate to high risk. Supplements containing vitamin C, zinc, and protein may support skin health in at-risk individuals.

Practical Mattress Features for Pressure Prevention

What to Look For

• Zoned construction: Different foam densities in different zones. Softer foam under shoulders and hips (where bony prominences contact the surface) and firmer foam under the lumbar and legs (where support is needed). This distributes pressure more evenly than uniform-density foam
• Immersion without bottoming out: The body should sink into the comfort layer enough to distribute pressure broadly, but not so deeply that the person contacts the firmer support layer underneath. Test by placing your hand between the person and the mattress surface at the heaviest pressure point. If you can feel the base layer, the mattress is bottoming out and is not providing adequate pressure redistribution
• Breathable cover: A cover that allows air circulation reduces moisture buildup and heat retention. Excessive heat and moisture increase skin vulnerability to pressure damage
• Low-friction surface: The outer cover should reduce friction during repositioning. Some covers are treated with friction-reducing coatings. A fitted sheet with low-friction fabric (cotton sateen, microfibre) also helps
• Waterproof protector compatibility: Many people at risk of pressure injuries also need incontinence protection. The mattress must perform well under a waterproof protector. Choose a protector that is breathable (polyurethane membrane) rather than vinyl, which traps heat

What to Avoid

• Old, sagging mattresses: A mattress that has lost its support properties concentrates pressure rather than distributing it. If the mattress sags more than 1.5 inches when unloaded, it needs replacing
• Very firm mattresses: An overly firm mattress does not allow adequate immersion, creating high peak pressures at bony prominences. For pressure-injury prevention, medium to medium-firm is better than firm
• Thick pillow-top mattresses: While soft, thick pillow-tops can compress unevenly, create heat pockets, and make repositioning difficult. The comfort layer should be supportive, not just soft
• Ring cushions and doughnut devices: These concentrate pressure around the ring edge rather than redistributing it. They are not recommended for pressure injury prevention

Setting Up a Pressure-Prevention Bedroom

Bed Height and Accessibility

• Set bed height for safe transfers. Too high increases fall risk. Too low makes caregiver repositioning difficult
• Ensure the bed can be accessed from both sides for repositioning
• Consider an adjustable base that allows head and foot elevation, which can help with repositioning and reduce sacral pressure when the head is slightly elevated

Bedding Selection

• Use smooth, wrinkle-free sheets. Bunched or wrinkled sheets create localized pressure points
• Avoid tucking sheets too tightly, which restricts movement and increases friction
• Use a breathable waterproof protector under the fitted sheet
• Keep bedding light. Heavy blankets add pressure and increase heat

Repositioning Aids

• Foam wedges (30-degree angle) for side positioning
• Pillows between knees and ankles to prevent bony prominence contact
• Heel elevation cushions or pillows to float heels off the mattress surface (heels are the second most common site for pressure injuries after the sacrum)
• Slide sheets for low-friction repositioning (reduce shear during turns)

Ontario Coverage and Financial Assistance

Pressure prevention equipment may be partially or fully funded through Ontario programs depending on the individual's circumstances:

• Ontario Health at Home: May provide specialized support surfaces for eligible patients receiving home care services. Contact your local Ontario Health at Home coordinator for assessment
• Assistive Devices Program (ADP): Ontario's ADP may fund certain pressure relief devices when prescribed by a healthcare provider. Coverage varies by device type and individual eligibility
• Ontario Disability Support Program (ODSP): ODSP recipients may access discretionary benefits for health-related equipment, including specialized mattresses, with healthcare provider documentation
• Veterans Affairs Canada (VAC): Veterans may receive coverage for pressure-prevention equipment through their treatment benefits program
• Private insurance: Some extended health benefit plans cover prescribed medical equipment. Check your plan for durable medical equipment coverage

Consumer mattresses (even high-quality ones selected for pressure relief) are not typically covered by these programs because they are not classified as medical devices. However, a quality consumer mattress may be the most cost-effective option for people at low to moderate risk who do not qualify for medical-grade equipment funding.

When to Seek Professional Assessment

A consumer mattress is appropriate for pressure prevention in low to moderate risk situations. Seek professional assessment from a healthcare provider when:

• The person has a stage 2 or higher pressure injury
• The person cannot reposition themselves at all (completely immobile)
• Skin breakdown continues despite proper mattress, repositioning, and skin care
• The person has multiple high-risk factors (immobility plus incontinence plus malnutrition)
• The person is being discharged from hospital after treatment for a pressure injury

In these situations, a formal risk assessment (Braden Scale or Norton Scale) by a wound care nurse or occupational therapist can determine whether a medical-grade support surface is needed.

Common Questions

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