Welcome to the latest edition of The Lowdown. On April 1, 2024, the Centers for Medicare & Medicaid Services (CMS) implemented enhanced barrier precautions (EBP) in nursing homes. EBP refers to an infection control intervention released by the Centers for Disease Control and Prevention (CDC) in 2019 to prevent the spread of multidrug-resistant organisms in long- term care facilities. This issue reviews the effectiveness of EBP to break the chain of transmission. Happy reading!
Stopping the Spread
To recognize the importance of EBP, one needs to know how pathogens (“germs”) are spread. Many different pathogens 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 include:1
- 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 a recent surgery; skin burn; diabetes; cardiopulmonary disease; immunosuppression; or an indwelling device, such as a Foley catheter, makes someone more susceptible
You can stop germs from spreading by breaking or interrupting this chain at any link. Ways to break the chain include frequent hand hygiene, vaccination (such as for COVID or influenza, aka a “flu shot”), cough and sneeze etiquette, following the rules for standard and contact precautions, using personal protective equipment (PPE) correctly, cleaning and disinfecting the environment, sterilizing medical instruments and equipment, following safe injection practices, and using antibiotics wisely to prevent antibiotic resistance.1
Bridging the Gap
Consistently following basic infection prevention practices is key to preventing spread of multidrug-resistant organisms (MDROs). Transmission-based precau- tions (i.e., contact, droplet, airborne) are implemented for residents who are known or suspected to be infected or colonized with an MDRO as well as those at increased risk of acquiring an MDRO, such as residents with wounds or indwelling medical devices. They are used when a route of transmission is not completely interrupted using standard precautions alone. This can be challenging when staff must balance resident quality of life with the need for implementing transmis- sion-based precautions, such as room restrictions and use of PPE.2,3
EBP is a bridge between standard and contact precautions to help address this challenge by expanding the use of PPE beyond blood and body fluid exposures. EBP recommends 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 EBP provides guidance for PPE use and room restriction in nursing homes for preventing transmission of MDROs. EBP requires gowns and gloves for certain residents during specific care activities but are 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.2,3
Use EBP for residents colonized with an MDRO or who have an indwelling medical device or wound. Wounds and indwelling devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) are risk factors for carrying or acquiring MDROs.2,3
EBP identifies the following high-contact resident activities that would 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 they are needed to follow standard precautions. Residents in EBP are not restricted to their rooms or stopped from participation in group activities.3
Contact Precautions Are Necessary
Contact precautions are required for:2,4
- 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
- Units or 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
Gowns and gloves must be worn when entering ANY contact precaution room and the resident is restricted to their room (except for medically necessary care).2,3
Additional Points to Remember
When implementing any type of transmission-based precautions or EBP, educate and reinforce facility expectations for hand hygiene, PPE use, environmental cleaning, and cleaning and disinfecting medical equipment/devices.3,4
For any resident with additional precautions:3,4
- Post clear signage on the door or wall outside their room
- Make PPE available immediately outside their room
- Make hand hygiene accessible; provide alcohol-based hand rub at every resident room
- Make trash receptacles readily available for PPE disposal
- Audit/monitor compliance with precautions and hand hygiene
- Educate staff, residents, family, and visitors on the importance of following the precautions
Resources
The following resources may help to implement or educate on EBP.
Patient Safety Authority webinar: Understanding Enhanced Barrier Precautions CDC Pre-Implementation Tool—Enhanced Barrier Precautions (EBP)
CDC Enhanced Barrier Precautions (EBP) Implementation—Observations Tool CDC Enhanced Barrier Precautions Pocket Guide
CDC Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs)
CDC Enhanced Barrier Precautions Letters
- For residents, families, friends, and volunteers
- For staff
- For leadership
Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007)
Examples of Safe Donning and Removal of PPE
CDC Appendix A: Type and Duration of Precautions Recommended for Selected Infections and Conditions
CDC Posters
- Enhanced Barrier Precautions Sign
- How We Keep Our Residents Safe
References
Association for Professionals in Infection Control and Epidemiology. Chain of Transmission. APIC Text Online. https://text.apic.org/the-apic-text-online. Published 2019. Accessed June 6, 2024.
Mody L, Bradley SF, Galecki A, et al. Conceptual Model for Reducing Infections and Antimicrobial Resistance in Skilled Nursing Facilities: Focusing on Residents With Indwelling Devices. Clin Infect Dis. 2011;52(5):654-61. doi: 10.1093/cid/ciq205
Centers for Disease Control and Prevention. Implementation of Personal Protective Equipment (PPE) in Nursing Homes to Prevent Spread of Novel or Targeted Multidrug-Resistant Organisms (MDROs). CDC website. https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html. Updated July 12, 2022. Accessed June 6, 2024.
Centers for Disease Control and Prevention. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007). CDC website. https://www. cdc.gov/infection-control/hcp/isolation-precautions/?CDC_AAref_Val=https://www.cdc.gov/ infectioncontrol/guidelines/isolation/index.html. Updated June 2023. Accessed June 6, 2024.
