The Centers for Medicare & Medicaid Services (CMS) has issued new guidance to long-term care providers and state survey agencies regarding enhanced barrier precautions (EBP). As of April 1, providers and surveyors must use personal protective equipment during high-contact care activities as a regular part of infection prevention and control standards. This guidance is designed to prevent broader transmission of multidrug resistant organisms (MDROs) and to help protect residents with chronic wounds and indwelling devices, according to the agency. The changes align CMS regulations with Centers for Disease Control and Prevention (CDC) guidance issued in 2022.

The new guidance calls for the use of EBP for any of these situations:

• Residents who have an infection or colonization with an MDRO when contact precautions do not otherwise apply.
• Residents with indwelling medical devices (even if it isn’t known whether the resident is infected or colonized with an MDRO). EBP is not necessary for peripheral intravenous lines, but devices that do qualify include:
  • Central lines, including PICC;
  • Urinary catheters;
  • Feeding tubes;
  • Tracheostomies.

• Although shorter-term wounds, such as skin breaks or tears covered with an adhesive bandage or other dressing, don’t require EBP, it should be utilized in residents with chronic wounds, including:
  • Pressure ulcers;
  • Diabetic foot ulcers;
  • Unhealed surgical wounds;
  • Venous stasis ulcers.

EBPs should be used for these residents during:

• Bathing;
• Device care;
• Dressing;
• Hygiene provision;
• Linen or underwear changes;
• Toileting assistance;
• Transfers;
• Wound care.

However, EBPs aren’t necessary when performing transfers in common areas (such as dining rooms), as contact is expected to be brief.

It is important to note that facilities have some discretion regarding the use of EBP for residents without chronic wounds or an indwelling catheter, even if they have an MDRO not currently targeted by the CDC. CDC-targeted MDROs include:

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

More than half of nursing home residents may be colonized with an MDRO, according to CMS. Nonetheless, the agency says that facilities can use some discretion when employing EBP to balance the need to maintain a homelike environment for residents with preventing the spread of infections. EBPs, it is important to note, aren’t the same as contact precautions. Instead, they are intended to be upheld for the length of the resident’s stay or until the wound resolves or indwelling medical device no longer is necessary.

Bruce Y. Lee, MD, an MDRO researcher from City University of New York, has found that contact precautions employed when handling nursing home residents colonized with MDROs benefit not only that particular nursing home but other LTC facilities and hospitals as well. Since residents are often transferred to other health facilities, residents carrying an MDRO can cause outbreaks in all of these settings. He asserts that, while EBPs could increase costs, the benefits of preventing infections outweigh the expenses. To download a tip sheet with this information, click here.

For more information, click here: https://www.cms.gov/files/document/qso-24-08-nh.pdf. For information on use of PPE in LTC, click here: https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html.