Classes of Support Surfaces Protection Status
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by Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS

According to the National Pressure Ulcer Advisory Panel (NPUAP, 2007), a support surface is “a specialized device for pressure redistribution designed for management of tissue loads, micro-climate, and/or other therapeutic functions (i.e. any mattresses, integrated bed system, mattress replacement, overlay, or seat cushion, or seat cushion overlay).” Because there is no method available to provide weightlessness for our patients, the next best thing we can do to prevent skin breakdown is to reduce pressure on bony prominences as much as humanly possible.

Regulations Mandating Support Surfaces

Federal regulations (Medicare) state that patients who have pressure ulcers, or who are at risk of developing pressure ulcers, must be afforded an appropriate support surface. Federal regulations also dictate which support surfaces may be used. Health organizations that fail to comply with these standards may be faced with both civil and criminal penalties. Federal regulations state that an individual who enters an institution or facility must be properly cared for in order to prevent pressure ulcers unless it can be shown that the pressure ulcers were an unavoidable consequence of the individual’s condition. In addition, the individual who enters an institution or facility and already has a pressure ulcer must be given appropriate treatment to heal the ulcer and prevent new pressure ulcers from forming, in addition to ensuring that the pressure ulcers do not become infected.

Classes of Support Surfaces

Class l support surface- a simple pressure pad device. A Class l support surface is required for the following patient situations:

  • Patients who cannot turn or move themselves to relieve pressure on bony prominences
  • Patients who have a pressure ulcer present on the pelvis or trunk (of any stage) and who also have impaired nutritional status, urinary or fecal incontinence, compromised circulation or altered sensory perception

Examples of a Class l support surface include: gel overlays, foam mattresses that are 3 to 5 inches thick, egg crate mattresses.

Class ll support surface- a device that relieves pressure over bony prominences. These devices reduce pressure for sustained periods of time to less than 32 mm Hg. A Class ll support surface is required for the following patient situations:

  • Patients who have multiple pressure ulcers on the pelvis or trunk; wounds not improved despite adequate and comprehensive treatment (including a Class l support surface for at least one month for stage II, III or IV pressure ulcers)
  • Patients that have large stage III or IV pressure ulcers on the pelvis or trunk
  • Patients who have had a skin grafting procedure/myocutaneous flap in the past 60 days to treat a pressure ulcer on the pelvis or trunk
  • Patients who were on a Class ll or lll support surface prior to a recent discharge from a nursing facility or hospital within the past month

Examples of Class ll support surfaces include: Renaissance mattress, ROHO® flotation mattress.

Class lll support surface- an advanced pressure-relieving device (air-fluidized bed). Note that this type of support surface may only be used when a comprehensive conservative treatment plan has failed after being implemented for 30 days, including family/patient education, optimization of nutritional status, appropriate wound care, use of a Class ll support surface, management of incontinence and appropriate positioning and turning. An example of a Class lll support surface is a Clinitron® bed.

Choosing the appropriate support surface for patients involves determining the patient’s risk for developing a pressure ulcer, the extent, depth and location of any pressure ulcers that have already formed and the treatment that has already been provided, the patient’s ability to move themselves in bed, the patient’s nutritional status and the overall health of the patient.

Terms and definitions related to support surfaces. (2007). National Pressure Ulcer Advisory Panel Support Surface Standards Initiative. Downloaded from

Stillman, R., Geibel, J., Daley, B., Talavera, F & Friedman, A. (2010). Wound care management and treatment. Medscape. Downloaded from

About The Author

Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS is a Certified Wound Therapist and enterostomal therapist, founder and president of, and advocate of incorporating digital and computer technology into the field of wound care.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

Effective Support Surface Selection


It may interest you to know that currently a five year study is being conducted at a major California University in collaboration with a large Rehabilitation Center of the
clinically proven cost-effective, patented Volkner Turning System mattresses/overlays for prevention and treatment of pressure sores. The study is in its final year, funded by NIH, involving 160 outpatients. Only half that number is using our Turning System while the Control Group of the other eighty patients has no access to it. James Consolidated, Inc., a woman owned small business, is the manufacturer in California, and sole source world wide of this innovative Turning System. In fact, the company was awarded an Export Achievement Certificate from the U.S. Department of Commerce on May 23, 2012, by California Congressman John Garamendi at the celebration of "World Trade Week" in Livermore, California.

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