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CMS Requires Enhanced Barrier Precautions in Nursing Homes

On March 20, 2024, the Centers for Medicare and Medicaid Services (CMS) issued memorandum QSO-24-08-NH for long term care (LTC) facilities incorporating Enhanced Barrier Precautions (EBP) into infection control procedures for multidrug-resistant organisms (MDROs), aligning with nationally accepted standards. The EBP standard was introduced by the Centers for Disease Control and Prevention (CDC) in 2019 and updated in July 2022 as a way of reducing transmission of MDROs when the more restrictive Contact Precautions do not apply. The standard was referenced in the October 2022 update to Appendix PP of the State Operations Manual. This new guidance related to EBP is now being incorporated into the F880 Infection Control tag and will begin being surveyed as an accepted national standard on April 1, 2024.

The EBP standard recommends the use of personal protective equipment (PPE), specifically targeting gown and glove use during high-contact activities, in addition to standard precautions used to reduce transmission of MDROs. EBP is recommended for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of the resident's MDRO status. CMS defines high-contact care activities as dressing, bathing, toileting, hygiene, transfers, changing bed linens, device, and wound care. Specific wounds that would require use of EBP include chronic wounds, not shorter-lasting wounds such as skin breaks, abrasions, or skin tears covered with an adhesive bandage or similar dressing. Chronic wounds requiring EBP include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. CMS further defines indwelling medical devices as central lines, urinary catheters, feeding tubes, and tracheostomies. A peripheral intravenous line [not a peripherally inserted central catheter (PICC)] is not considered an indwelling medical device for the purpose of EBP.

In general, gowns and gloves would not be recommended when performing transfers in common areas such as dining or activity rooms, where contact is anticipated to be shorter in duration. Likewise, PPE for EBP may not need to be donned prior to entering the resident’s room. For example, staff entering the resident’s room to answer a call light, converse with a resident, drop off a meal tray, or provide medications who do not engage in a high-contact resident care activity would likely not need to employ EBP while interacting with the resident.

Examples of when EBP is recommended outside the resident’s room include when in a shared/common shower room assisting during bathing or performing transfers, and when working with residents in the therapy gym specifically when anticipating close physical contact while assisting with transfers and mobility.

CMS notes that facilities have discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO that is not currently targeted by the CDC. For the purposes of the QSO, the MDROs for which the use of EBP applies are based on local epidemiology. At a minimum, they should include resistant organisms targeted by the CDC, but can also include other epidemiologically important MDROs.

Examples of MDROs targeted by the CDC include:

  • Pan-resistant organisms;
  • Carbapenemase-producing carbapenem-resistant Enterobacterales;
  • Carbapenemase-producing carbapenem-resistant Pseudomonas spp.;
  • Carbapenemase-producing carbapenem-resistant Acinetobacter baumannii; and
  • Candida auris.

Additional epidemiologically important MDROs may include, but are not limited to:

  • Methicillin-resistant Staphylococcus aureus (MRSA);
  • Extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales;
  • Vancomycin-resistant Enterococci (VRE);
  • Multidrug-resistant Pseudomonas aeruginosa; and
  • Drug-resistant Streptococcus pneumoniae.

Facilities also have some discretion when implementing EBP and balancing the need to maintain a homelike environment for residents. When instituting EBP, use of CDC resources will be extremely helpful. A CDC video presentation on EBP is available here, and the slides from the presentation are here. More information on how this standard will be surveyed will be made available in the Surveyor Resources file in the Downloads section of the CMS Nursing Homes webpage. For questions or concerns relating to the QSO, please contact DNH_TriageTeam@cms.hhs.gov.

Contact: Carrie Mosley, cmosley@leadingageny.org, 518-867-8383 ext. 147