CDC Issues Updated Guidance for Enhanced Barrier Precautions Against MDROs for Nursing Homes

On the July 13^th Centers for Medicare and Medicaid Services (CMS) National Nursing Home Stakeholder Call, there was a presentation on the updated Centers for Disease Control and Prevention (CDC) enhanced barrier precautions (EBP) guidance for multidrug-resistant organisms (MDROs) for nursing homes. The presentation slides will be posted on the CDC website in the near future.

EBP expand the use of personal protective equipment (PPE) and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident to resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization.

Examples of high-contact resident care activities requiring gown and glove use for EBP include:

• Dressing
• Bathing/showering
• Transferring
• Providing hygiene
• 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

In general, gown and gloves would not be required for resident care activities other than those listed above, unless otherwise necessary for adherence to standard precautions. Residents are not restricted to their rooms or limited from participation in group activities. Because EBP do not impose the same activity and room placement restrictions as contact precautions, they are intended to be in place for the duration of a resident’s stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.

Key points from the guidance include the following:

1. MDRO transmission is common in nursing homes, contributing to substantial resident morbidity and mortality and increased health care costs.
2. EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high-contact resident care activities.
3. EBP may be indicated (when contact precautions do not otherwise apply) for residents with any of the following:
   • Wounds or indwelling medical devices, regardless of MDRO colonization status;
   • Infection or colonization with an MDRO.
4. Effective implementation of EBP requires staff training on the proper use of PPE and the availability of PPE and hand hygiene supplies at the point of care.
5. Standard precautions, which are a group of infection prevention practices, continue to apply to the care of all residents, regardless of suspected or confirmed infection or colonization status.

For the purposes of this guidance, 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: