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Current estimates are that more than 50% of long-term care (LTC) residents may be colonized with multidrug-resistant organisms (MDROs).1 To address this reality, the Centers for Medicare and Medicaid Services (CMS) implemented a requirement for enhanced barrier precautions for long-term care facilities effective April 1, 2024. Enhanced barrier precautions are designed to reduce transmission of MDROs, resident morbidity and mortality, and healthcare costs.2 

Multiple infection prevention practices are required to prevent the transmission of MDROs in LTC facilities. These practices include hand hygiene, environmental cleaning, proper handling of wounds, indwelling medical devices, and resident-care equipment.2 Additionally, when a resident is colonized or infected with an MDRO and contact precautions do not apply, enhanced barrier precautions are used in addition to standard precautions. 

Enhanced barrier precautions are infection prevention practices to use when providing high-contact care activities to these residents. The goal is to reduce MDRO transmission through targeted use of gowns and gloves during care activities where there is an elevated risk for MDRO transfer to staff hands and clothing. High-contact care activities include dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting, and medical device care (i.e., central lines, urinary catheters, feeding tubes, tracheostomy, ventilator care, and wound care for any skin opening requiring a dressing).2 Enhanced barrier precautions also apply to caring for wounds and indwelling medical devices when MDRO colonization or infection status is unknown or has not been diagnosed in the resident.

Enhanced barrier precautions may seem similar to contact precautions, but they do not include all elements of contact precautions. Contact precautions require a higher level of transmission precautions by providing residents with dedicated equipment, a private room or cohorting of residents, and restricting them to their room and from participating in group activities.2 Enhanced barrier precautions guidance does not recommend these practices and in fact recommends that residents should not be restricted to their rooms or limited from group activities when using enhanced barrier precautions. The CMS guidance also indicates that facilities may use discretion when utilizing enhanced barrier precautions and balancing the need to maintain a homelike environment for residents.3   

Enhanced barrier precautions are implemented, at a minimum, for targeted resistant organisms specified by the Centers for Disease Control (CDC) and other MDROs that are considered epidemiologically important.2 Examples of CDC targeted MDROs include pan-resistant organisms, carbapenemase-resistant or producing Enterobacter ales, carbapenemase-resistant or producing Pseudomonas, carbapenemase-resistant or producing Acinetobacter baumannii, and Candida auris. Among epidemiologically important MDROs are Methicillin-resistant Staphylococcus aureus (MRSA), ESBL-producing Enterobacter ales, Vancomycin-resistant Enterococci (VRE), multidrug-resistant Pseudomonas aeruginosa, and drug-resistant Streptococcus pneumoniae.2

Implementing Enhanced Barrier Precautions

The new enhanced barrier precautions guidance is incorporated in F880 (Infection Prevention and Control) for LTC surveyors when evaluating the facility’s use of enhanced barrier precautions.1 When initiating an enhanced barrier precautions program2: 

• Develop/update facility infection prevention policies and procedures.
• Post clear signage on the resident’s door or wall outside their room indicating the type of precautions and required personal protective equipment (PPE). Enhanced barrier precautions signage should include the high-contact resident care activities that require a gown and gloves.
• Have PPE available immediately outside the resident’s room.
• Ensure there is access to alcohol-based hand rub in every resident's room, preferably inside and outside of the resident's room.
• Provide education to residents and visitors.

Risk Management Considerations

Here are some questions you may need to answer when considering your facility’s implementation of enhanced barrier precautions:

• Do your current policies and procedures follow the guidelines set forth by CMS for enhanced barrier precautions?
• How will you identify current residents colonized with an MDRO?
• Who will be responsible for:
  • Obtaining the resident’s colonization status on new admits?
  • Ensuring enhanced barrier precautions are implemented when a resident’s condition changes (development of a wound, active infection, or newly implanted device)?
  • Ensuring proper signage on resident doors and maintaining alcohol rub dispensers?
  • Documenting the resident’s enhanced barrier precautions status?
• How does this impact your PPE usage and supply needs?
• Does your facility assessment need to be updated to include these requirements?
• Does this impact your staffing pattern or room assignment considerations?
• How will you address resident and family concerns regarding these new requirements?
• How will you continue to facilitate a home-like environment for the residents while adhering to this guidance?

Additionally, ongoing staff education and observation for guideline adherence is essential to facilitate compliance. As this concept is completely new, frequent training and reminders for all staff are indicated until sustained compliance is achieved in the facility. At this point, add routine observations for compliance into your monthly infection control rounding. Provide ongoing periodic refresher training for staff on facility enhanced barrier precautions policies and procedures. As always, ensure you retain documentation of all staff training you provide.  

For additional questions or resources regarding enhanced barrier precautions, please contact LAMMICO’s Long-Term Care Facility Specialist, Emily Jones at 504-841-2733 or ejones@lammico.com.

References

1. Centers for Medicare & Medicaid Services. Enhanced barrier precautions in nursing homes. March 20, 2024. https://www.cms.gov/files/document/qso-24-08-nh.pdf
2. Centers for Disease Control. Implementation of personal protective equipment (PPE) use in nursing homes to prevent spread of multidrug-resistant organisms (MDROs). July 12, 2022.  https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html?CDC_AAref_Val=https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html
3. Miller, A. CMS implements enhanced barrier precautions effective April 1, 2024. March 20, 2024. https://www.ahcancal.org/News-and-Communications/Blog/Pages/CMS-Implements-Enhanced-Barrier-Precautions-Effective-April-1-2024.aspx