Welcome to the latest issue of The Lowdown. The Centers for Disease Control and Prevention (CDC) released Enhanced Barrier Precautions (EBPs) in 2019 to prevent the spread of novel or targeted multidrug-resistant organisms (MDROs) in long-term care facilities. This issue is a review of EBPs to break the chain of transmission. Happy reading!
BREAK THE CHAIN—STOP THE SPREAD!
The diagram represents the “chain” or cycle of transmission of an infection. Many different pathogens (“germs”) are found inside and outside a healthcare facility. These germs spread from one person to another through a common series of events: the “chain of transmission.” Breaking the chain at any point in the cycle prevents the germ from infecting more people.1 The links of the chain include1
- Infectious Agent—germ that causes disease
- Reservoir—where the germ lives (people, equipment, vectors such as ticks or mosquitoes)
- Portal of Exit—how the germ leaves the reservoir (coughing, sneezing, body fluids)
- Mode of Transmission—how the germ is passed on (direct or indirect contact, fomites, ingestion, inhalation)
- Portal of Entry—how the germ enters the new host (mucous membranes, respiratory tract, broken skin, gastrointestinal tract, catheters)
- Susceptible Host—can be anyone, but having recent surgery, burns, diabetes, immunosuppression, cardiopulmonary disease, or indwelling devices such as Foley catheters makes someone more susceptible
The way to stop germs from spreading is by breaking or interrupting this chain at any link. Ways to break the chain include frequent hand hygiene, vaccination (including COVID or influenza—“flu shot”), cough and sneeze etiquette, following the rules for Standard and Contact Precautions, using personal protective equipment (PPE) the right way, cleaning and disinfecting the environment, sterilizing medical instruments and equipment, following safe injection practices, and using antibiotics wisely to prevent antibiotic resistance.1 Long-term care infection prevention tools for residents and visitors are available from the Association for Professionals in Infection Control and Epidemiology (APIC) at https://apic.org/consumers/materials-for-healthcare-facilities/
Bridge the Gap With Enhanced Barrier Precautions
Consistently following basic infection prevention practices is key to preventing spread of multidrug-resistant organisms (MDROs). Transmission-Based Precautions (Contact, Droplet, Airborne) are implemented for residents who are known or suspected to be infected or colonized with certain epidemiologically important pathogens, and are used when the route(s) of transmission are not completely interrupted using Standard Precautions alone. This can be a challenge when staff must balance resident quality of life with the need for implementing Transmission- Based Precautions, such as room restrictions and use of PPE.2,3
Enhanced Barrier Precautions (EBPs) are a bridge between Standard and Contact Precautions to help address this challenge. EBPs expand use of PPE beyond blood and body fluid exposures. They recommend the use of PPE for high-contact resident care activities that have been found to result in transfer of MDROs to the hands and clothing of staff.2,3 EBPs provide guidance for PPE use and room restriction in nursing homes for preventing transmission of novel or targeted MDROs. EBPs require gowns and gloves for certain residents during specific care activities but is not as restrictive as Contact Precautions, as the resident is not restricted to their room and PPE is not required for every entry into the room.
EBPs are recommended for residents colonized with a novel or targeted MDRO or residents with indwelling medical devices or wounds living on the unit or wing where a resident known to be infected or colonized with a novel or targeted MDRO lives. Wounds and indwelling devices (central line, urinary catheter, feeding tube, tracheostomy/ventilator) are risk factors for carrying or acquiring MDROs.2 Because of this, some facilities have decided to implement EBPs for all residents in the facility with indwelling medical devices or wounds, regardless of the presence of a novel or targeted MDRO.2,3
Novel or targeted MDROs:2,3
- Pan-resistant organisms—organisms that are resistant to all current antibacterial agents
- Carbapenemase-producing Enterobacteriaceae
- Carbapenemase-producing Pseudomonas spp.
- Carbapenemase-producing Acinetobacter baumannii
- Candida auris EBPs identify the following high-contact resident activities to require gown and glove use:2,3
- Dressing
- Bathing/showering
- Transferring
- Providing hygiene (focused on a.m. and p.m. care)
- Changing linens
- Changing briefs or assisting with toileting
- Device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator)
- Wound care (any skin opening requiring a dressing)
Gowns and gloves would not be required for resident care activities other than those listed above, unless needed to follow Standard Precautions. Residents in EBPs are not restricted to their rooms or stopped from participation in group activities.3
Times for Contact Precautions
Contact Precautions are required for:2
- All residents with an MDRO when there is acute diarrhea, draining wounds, or other sites of secretions or drainage that can’t be contained or covered
- On units or in facilities where ongoing transmission is documented or suspected
- C. difficile infection
- Norovirus
- Shingles when resident is immunocompromised and vesicles cannot be covered
- Other conditions as noted in CDC Appendix A - Type and Duration of Precautions Recommended for Selected Infections and Conditions: https:// www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/type-duration- precautions.html
Gowns and gloves must be used for ANY room entry and the resident is restricted to their room except for medically necessary care.2,3
It’s More Than Just Gowns and Gloves
When implementing any type of Transmission-Based Precautions or EBPs, it is important to provide education and reinforce facility expectations for hand hygiene, PPE use, environmental, and the cleaning and disinfection of medical equipment/ devices.
For any resident in additional precautions:
- Post clear signage on the door or wall outside the room
- Make PPE available immediately outside the room
- Make hand hygiene accessible; provide alcohol-based hand rub at every resident room
- Make trash receptacles readily available for PPE disposal
- udit/monitor compliance with precautions and hand hygiene
- Provide education to residents, family, and visitors
- Educate staff on the importance of following the precautions
References
- Association for Professionals in Infection Control and Epidemiology. Chain of Transmission. APIC Text Online. https://text.apic.org/the-apic-text-online. Pub- lished 2019. Accessed September 20, 2021.
- Mody L, Bradley SF, Galecki A, Olmsted RN, Fitzgerald JT, Kauffman CA, Saint S, Krein SL. Conceptual Model for Reducing Infections and Antimicrobial Resistance in Skilled Nursing Facilities: Focusing on Residents With Indwelling Devices. Clin Infect Dis. 2011 Mar 1;52(5):654-61. doi: 10.1093/cid/ciq205.
- Centers for Disease Control and Prevention. Implementation of Personal Protec- tive Equipment (PPE) in Nursing Homes to Prevent Spread of Novel or Targeted Multidrug-resistant Organisms (MDROs). CDC website. https://www.cdc.gov/hai/ containment/PPE-Nursing-Homes.html. Published 2019. Accessed September 20,
- 2021.
- Centers for Disease Control and Prevention. Guideline for Isolation Precau- tions: Preventing Transmission of Infectious Agents in Healthcare Settings. CDC website. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html. Published 2007. Accessed September 20, 2021.
