Choosing a pressure care mattress is a common and complex clinical decision. Foam, hybrid, alternating air, and low air loss surfaces all have a role, but none is universally “best”.
International best-practice guidance takes a process-based approach to support surface selection. Rather than promoting a specific mattress type, it emphasises assessing pressure injury risk, identifying individual needs, and matching those needs to surface features with regular reassessment over time.
This article outlines that process and explains how to decide which type of pressure care mattress to consider in the first place.
Figure 1: Mattress systems and support surfaces
Start With the Guideline Process: Assess Risk First
Effective pressure injury prevention begins with comprehensive risk assessment and consistent skin and tissue monitoring.
This includes:
- level of pressure injury risk
- current or previous pressure injuries
- skin condition and tissue tolerance
- ability to reposition independently or with assistance
Importantly, pressure injury risk assessment is not a one-off task. Risk can change rapidly with illness, reduced mobility, pain, or changes in care environment, and mattress selection should change accordingly.
Figure 2: Risk Assessment Purpose T Tool in Enable Lifecare app
(Click here to access Enable Lifecare App)
Mattress Selection Is About Needs, Not Labels
A guideline-aligned approach does not support choosing a mattress based solely on its category (e.g. foam vs air). Instead, they recommend matching the support surface to the individual’s specific needs, including:
- pressure redistribution requirements
- mobility, activity, and ability to reposition
- comfort, tolerance, and sleep quality
- need for microclimate management (heat and moisture)
- care setting and feasibility (home, RACF, acute care)
This is why two people with the same risk score may legitimately need different mattress types.
What Support Surfaces Are Designed to Do
Full-body support surfaces are designed to:
- redistribute pressure
- reduce friction and shear
- assist with microclimate management (heat and moisture at the skin–surface interface)
Different mattress types achieve these goals in different ways, each with their own trade-offs.
Understanding the Main Mattress Categories
Once risk and needs are clear, clinicians can consider which category of mattress is most appropriate.
Figure 3: Types of Support Surfaces
Reactive foam mattresses
Reactive foam mattresses provide continuous pressure redistribution by allowing the body to immerse into the surface.
They are commonly used:
- for people at risk of pressure injury
- when mobility and transfers need to be preserved
- in home and residential care settings
They rely on:
- appropriate immersion and envelopment
- regular repositioning and movement
Reactive foam is often an appropriate first-line option, as supported by the guidelines, provided the mattress is fit for the individual.
Figure 4: Reactive foam mattresses
Hybrid and reactive air mattresses
Hybrid or reactive air mattresses combine foam and air components to enhance immersion and envelopment, while remaining static (non-alternating).
They may be considered when:
- pressure redistribution needs exceed what standard foam can provide
- comfort and tolerance are priorities
- maintaining transfer ability is important
These surfaces still rely on repositioning, but may offer improved pressure distribution for some individuals.
Some hybrid mattresses can operate in both static and alternating modes. When used without alternating cycles, they function as a reactive support surface. When connected to a pump and set to alternating mode, they function as an active support surface.
An alternating hybrid surface may be considered when:
- pressure injury risk remains elevated despite appropriate reactive support
- the person has limited ability to reposition independently
- periods of sustained pressure need to be reduced, but full alternating air may compromise comfort or function (e.g. palliative care context)
- flexibility is needed to step up or step down support as risk changes (e.g. progressive conditions)
Figure 5: Alternating Hybrid (air-foam) mattresses
Alternating (active) air mattresses
Alternating air mattresses redistribute pressure over time, using cyclic inflation and deflation of air cells to provide periodic offloading.
They may be appropriate when:
- pressure injury risk remains high despite reactive surfaces
- the person is immobile
- there is a need to reduce the duration of sustained pressure
However, it is equally important to consider:
- comfort and sleep disruption
- impact on mobility and transfers
- feasibility (power supply, alarms, maintenance)
Alternating air is not automatically a higher level of care. It is one option among several.
Figure 6: Alternating air mattresses
Function, Comfort, and Feasibility Matter
Best practice requires consideration of mobility, comfort, and care context when selecting a support surface.
This means asking:
- Can the person reposition or transfer safely on this mattress?
- Will they tolerate the surface overnight?
- Does it suit the care environment and available support?
- Does the mattress align with the person’s goals, preferences, and daily routines?
A mattress that reduces pressure but compromises function or comfort may ultimately increase risk, not reduce it.
Tools such as the QUEST (Quebec User Evaluation of Satisfaction with Assistive Technology) can support this process by prompting structured conversations around function, comfort, ease of use, and overall satisfaction. Comfort scales may also be used to capture the person’s perceived comfort, tolerance, and sleep experience over time.
Using Decision-Support Tools to Guide Selection
Because mattress selection involves balancing multiple factors, decision-support tools can be helpful when used within a guideline-aligned process.
Tools such as the Enable Lifecare app's Pressure Mattress Selector are designed to:
- prompt consideration of pressure injury risk
- guide clinicians through key selection factors
- support consistent, evidence-informed decision-making
They are most effective when used after risk assessment and alongside clinical judgement, not as a replacement for either. Outcome measures, pressure mapping data, and selection tools are intended to support best-fit decision-making, rather than override clinician reasoning.
Reassessment Is Part of the Process
The guidelines emphasise the importance of ongoing reassessment.
A mattress should be reviewed when:
- skin condition changes
- pressure injuries develop or fail to improve
- mobility or tolerance changes
- care environment or goals of care shift
Changing the support surface is not a failure. It is a normal part of responsive, person-centred care.
Key Takeaways for Clinical Practice
- The International Pressure Injury Guidelines support a process-based approach to mattress selection
- Start with pressure injury risk assessment, then identify individual needs
- Choose a mattress category that matches pressure redistribution, function, comfort, and feasibility
- Use tools and apps to support, not replace, clinical reasoning
- Reassess regularly and adapt as needs change
Choosing a pressure care mattress isn’t about picking the “best” product.
It’s about following the right process to find the best fit for the person, at that time.
This process reflects current international best practice for pressure injury prevention and support surface selection.
Products and App links:
- Foam Mattress
- Hybrid Foam-Air Mattress
- Alternating Air Mattress
- Enable Lifecare App - Mattress Selector Tool
References
European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, & Pan Pacific Pressure Injury Alliance. (2019). Prevention and treatment of pressure ulcers/injuries: Clinical practice guideline – Support surfaces. https://www.internationalguideline.com/surfaces
(Accessed 6 February 2026)
