Enhanced Barrier Precautions: A New Approach to Preventing the Spread of Multidrug-Resistant Organisms in Nursing Homes

Nursing homes can present a challenge for infection prevention efforts when teams must balance resident quality of life with the need for measures such as room restrictions and use of personal protective equipment (PPE). 

These facilities are ripe for transmission of multidrug-resistant organisms (MDROs), but new evidence suggests use of traditional Contact Precautions may not be adequate. 

To fill the gap, the US Centers for Disease Control and Prevention (CDC) has recently unveiled a new approach called Enhanced Barrier Precautions (EBPs), which rank in between Standard and Contact Precautions, and “require gown and glove use for certain residents during specific high-contact resident care activities that have been found to increase risk for MDRO transmission,” according to the CDC. 

In an email Q&A with Infection Control Today, Kara M. Jacobs Slifka, MD, MPH, and Nimalie D. Stone, MD, MS, both physicians with the Long-term Care Team in the Prevention and Response Branch within CDC Division of Healthcare Quality Promotion, provide an in-depth overview of EBPs and how to implement them. 

Infection Control Today: Why do multidrug-resistant organisms pose such a threat in nursing homes, in particular, as opposed to other healthcare facilities? 

Drs. Jacobs Slifka and Stone: Multidrug-resistant organisms (MDROs), especially those for which we have limited antibiotic treatment options, pose a threat in healthcare because they colonize individuals for prolonged periods of time, silently spread, and cause invasive infections with high morbidity and mortality. As healthcare delivery keeps shifting away from hospitals, nursing homes are providing more care to medically complex and frail individuals who are more vulnerable to the harms from MDROs. The combination of the long lengths of stay, exposures to indwelling medical devices and antibiotics, and the increased dependence of nursing home residents contribute to the spread and acquisition in this setting. 

ICT: What are some of the current gaps in infection prevention practices in nursing homes that need to be addressed?

Drs. Jacobs Slifka and Stone: The key to preventing spread of MDROs comes down to consistently following basic infection prevention and control practices during care at the bedside; however, health department and CDC teams have routinely found gaps in these practices during visits to nursing homes across the country. The most common infection prevention gaps involve hand hygiene, the use of personal protective equipment (PPE) and precautions, and cleaning and disinfection of environmental surfaces and shared equipment. The implementation of these practices depends on 3 things: 1) educating healthcare staff about when and how to perform these infection prevention practices, 2) ensuring adequate supplies are available at the point of use, such as resident rooms and care areas, and 3) monitoring and providing feedback on staff adherence to practices. The incorporation of these practices is critical during all aspects of resident care from physical therapy to wound care. As an example, during our visits, we commonly hear misconceptions about the use of alcohol-based hand rub (AHBR) such as ABHR not being as effective as soap and water, or that adding ABHR dispensers will reduce the “home-like environment” of the nursing home and have the potential to be cited during the survey process. However, ABHR is the preferred method of hand hygiene unless hands are visibly soiled or during a Clostridioides difficileor norovirus outbreak, and increasing access to ABHR, such as inside and outside of resident rooms, increases staff adherence to hand hygiene. Performing hand hygiene audits is informative for providing feedback and determining the need for education or intervention. 

ICT: In nursing home facilities, why is it challenging to rely on the routine contact isolation precautions used in hospitals when there’s an outbreak of a multidrug-resistant organism? 

Drs. Jacobs Slifka and Stone: The main challenge with implementing Contact Precautions in the nursing home setting is the need to restrict residents to their room, especially when the reason for Contact Precautions is a multidrug-resistant organism (MDRO). Residents colonized with MDROs are often colonized for prolonged periods of times (ie, greater than 6 months) and typically have longer stays at the nursing home than in an acute care hospital. Limiting a resident’s movement and participation in the facility for extended lengths of time can impact rehabilitation, involvement in social activities, and negatively affect their well-being. For this reason, Contact Precautions are intended to be time-limited, while Enhanced Barrier Precautions can provide a more balanced and sustainable approach to MDRO prevention. 

ICT: What are Enhanced Barrier Precautions (EBPs) and how do they differ from standard and contact precautions?

Drs. Jacobs Slifka and Stone: Enhanced Barrier Precautions (EBP) expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated and recommends the use of gown and gloves during high-contact resident care activities that have been shown to provide opportunities for transfer of MDROs to staff hands and clothing. Enhanced Barrier Precautions falls on the spectrum in between Standard Precautions and Contact Precautions. Standard Precautions should be followed with all residents at all times, including residents for whom EBP or Transmission-Based Precautions are being used. EBP is more specific than Standard Precautions by requiring PPE use for high-contact resident-care activities, but less restrictive than Contact Precautions as PPE is not required for every room entry/activity and residents are not restricted to their rooms. 

ICT: What are some of the high-contact resident care activities where EBPs should be used?

Drs. Jacobs Slifka and Stone: High-contact resident care activities include: dressing, bathing/ showering, transferring, providing hygiene such as brushing teeth and combing hair, changing linens, changing briefs or assisting with toileting, device care or use (including: central line, urinary catheter, feeding tube, tracheostomy/ventilator, and wound care).

ICT: How can healthcare administrators ensure proper implementation of EBPs? 

Drs. Jacobs Slifka and Stone: Healthcare administrators can help by prioritizing infection prevention within their facility. This includes providing dedicated staff time to implement the infection prevention program. EBP will be a new concept for many nursing homes; staff, residents, and families will need to be educated. Administrators can also help by ensuring that staff have access to the supplies they need to follow recommended practices. Adherence to hand hygiene in a facility isn’t going to improve if staff don’t have access to alcohol-based hand rub at the point of care. Similarly, staff aren’t going to use PPE or clean and disinfect shared equipment after each use if they have to search the unit to find supplies. 

ICT: Anything else you would like to add about EBPs?

Drs. Jacobs Slifka and Stone: Using EBP to prevent the spread of MDROs helps facilities support resident safety and resident well-being but will require education of staff, residents, and families. CDC is developing additional materials to support implementation of EBP such as a list of Frequently Asked Questions. CDC recently presented a webinar introducing the need for and describing EBP, which is available online; has developed signage for EBP and Transmission-Based Precautions; and has released a comprehensive infection prevention training course for nursing homes.