Enhanced Barrier Precautions in Long-Term Care: A CMS Update

What do you do if you discover that 50% of your healthcare residents are colonized with a multi-drug resistant organism (MDRO)? You'd probably adjust your personal protective equipment protocols at your facility, right? Now consider this at a national scale: A 2021 Centers for Disease Control and Prevention (CDC) report revealed that "more than 50% of nursing home residents may be colonized with an MDRO," prompting the CDC to update its recommendations in July 2022, focusing on Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling medical devices, who are at higher risk for MDRO colonization and transmission. In today's post, we'll look at what this means for long-term care facilities.

Tackling antimicrobial resistance is crucial, especially in nursing homes where traditional contact precautions have proven insufficient for preventing the transmission of MDROs. In an acute setting, confining a patient to their room would be a reasonable restriction due to the risk of pathogen transmission, but this approach does not work in long-term settings. In nursing homes, skilled nursing facilities and other settings where patients live on-site for months and even years at a time, confining colonized patients to their rooms has serious negative outcomes on patient quality of life. The answer? Enhanced Barrier Precautions, or EBP.

EBP, introduced in 2019, employs targeted gown and glove use during high-contact activities with close physical contact, when the patient has wounds or is using an indwelling medical device, (whether or not the patient is colonized with an MDRO) to prevent MDRO spread in long-term care settings. Let's break down some of these definitions.

Close physical contact |  Close physical contact includes any activity that involves direct care, such as bathing or toileting. In these cases, the staff member would be in physical contact with the patient for the duration of an activity.

Wounds | Chronic rather than short-term skin breaks/tears (like a scratch covered with a bandage). This would include pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous statis ulcers.

Indwelling devices | A medical device that is partially inside the patient's body and partially outside the patient's body, therefore providing a means of pathogen transmission. These include central lines, urinary catheters, feeding tubes, and tracheostomy tubes. Note that as regards to EBP, indwelling devices do not include periphery IVs or ventilators.

Colonization | Not all patients will be tested for colonization, nor should they be according to these new recommendations. Some facilities, such as Veteran's Health Administration facilities, screen for MRSA on admission and assign positive patients to EBP. Under these guidelines, all patients should receive EBP under the conditions listed above (contact, wounds, devices).

RELATED: The Most Common Infections in Nursing Homes

Infection Preventionists (IPs) in nursing homes now have updated EBP compliance guidelines to consider. Effective April 1, 2024, surveyors will assess the use of EBP when conducting resident tracers, that is, when tracing the patient's care through the facility and/or system. These new guidelines will hopefully reduce the risk of MDRO transmission in long-term care facilities, but also come at a time when staff shortages are common and "PPE fatigue" is heightened. Implementing these guidelines will take significant education, financial investment, time, and surveillance. The success of these guidelines may come down to leadership paired with stakeholder investment in the initiative. 

MDROs will continue to be a challenge to all healthcare facilities, but particularly to long-term nursing homes and skilled nursing facilities which not only care for the most vulnerable populations but also have the tightest budgets. New technologies offer these facilities an additional layer of protection that can often be a safety net in these challenging times. For example, biocidal surfaces that continuously kill bacteria (even MDROs) can help keep contamination low, even in common areas shared by all patients. 

What do you think about these enhanced barrier protections? Share your thoughts in the comments below!