Enhanced Barrier Precautions
Issued By: Nursing
Effective Date: 11/1/22
Revised: 4/1/24
Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices). EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.
Recommendations for Use
Enhanced Barrier Precautions are recommended for residents with any of the following (even if the resident is not known to be infected or colonized with a MDRO):
- Infection or colonization with a MDRO
- A wound regardless of MDRO status (The intent of Enhanced Barrier Precautions is to focus on residents with a higher risk of acquiring an MDRO over a prolonged period of time. This generally includes residents with chronic wounds and not those with only shorter-lasting wounds such as skin breaks or skin tears covered with a Band-aid or similar dressing. Examples of chronic wounds include but are not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous status ulcers.)
- Care and use of indwelling medical device regardless of MDRO status (Examples of indwelling medical devices include but are not limited to central vascular lines (including hemodialysis catheters), indwelling urinary catheters, feeding tubes, and tracheostomy tubes.) A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP.
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 CDC. While prior iterations of the Enhanced Barrier Precautions guidance were intended for use solely during public health response activities, Enhanced Barrier Precautions are currently recommended to be used broadly in all units across the whole facility for residents who meet the above criteria.
Application and Duration of Enhanced Barrier Precautions
Require the use of gown and gloves only for high-contact resident care activities (unless otherwise indicated as part of Standard Precautions):
- 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
Residents are not restricted to their rooms and do not require placement in a private room. Residents are allowed to participate in group activities. EB Precautions remain 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.
Gowns and gloves are the minimum level of PPE required for these high-contact resident care activities. Additional PPE may be required depending on the resident. For example, face protection would also be required for activities where splashes and sprays are likely (e.g. wound irrigation, tracheostomy care). Note: 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. Outside the resident’s room, EBP should be followed when performing transfers or assisting during bathing in a shared/common shower room and when working with residents in the therapy gym specifically when anticipating close physical contact while assisting with transfers and mobility.
When residents are placed in shared rooms, BQNH will implement strategies to help minimize transmission of pathogens between roommates, including:
- Maintaining spatial separation of at least 3 feet between beds to reduce opportunities for inadvertent sharing of items between the residents
- Use of privacy curtains to limit direct contact
- Cleaning and disinfecting any shared reusable equipment
- Cleaning and disinfecting environmental surfaces on a more frequent schedule
- Changing personal protective equipment (if worn) and performing hand hygiene when switching care from one roommate to another.
Implementation of Enhanced Barrier Precautions
- Provide education to residents and visitors
- Disposal of PPE
- PPE used during resident care, including care of residents placed in Enhanced Barrier or Transmission-Based Precautions, would not fall into the category of regulated medical waste requiring disposal in a biohazard bag and could be discarded as routine non-infectious waste. Facilities should remember to have an appropriate disposal container available in the resident room to allow for removal of PPE inside the room.
- PPE Shortage
- When there are not enough gowns and gloves for implementation of EBP as recommended, facilities may temporarily prioritize EBP for residents with wounds over residents with indwelling medical devices alone. Risk of healthcare personnel self-contamination with S. aureus and MDROs is higher during care of residents with wounds compared to residents with indwelling medical devices alone. During PPE shortages, facilities should document all actions taken to remedy the shortage.
- Set Up
- Facilities have discretion on how to communicate to staff which residents require the use of EBP. CMS supports facilities in using creative (e.g. subtle) ways to alert staff when EBP use is necessary to help maintain a home-like environment as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities.
- Facilities should ensure PPE and alcohol-based hand rub are readily accessible to staff. Discretion may be used in the placement of supplies which may include placement near or outside the resident’s room.
- PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and 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, 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
- A trash can large enough to dispose of multiple gowns should be available for each room.
PPE use when transferring a resident from a wheelchair to chair in the dayroom or dining room
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. Enhanced Barrier Precautions is primarily intended to apply to care that occurs within a resident’s room where high-contact resident care activities including transfers are bundled together with other high-contact activity such as part of morning or evening care. This extended contact with the resident and their environment increases the risk of MDRO spreading to staff hands and clothes. Outside the resident’s rooms, Enhanced Barrier Precautions should be followed when performing transfers and assisting during bathing in a shared/common shower room and when working with residents in the therapy gym specifically when anticipating close physical contact while assisting with transfers and mobility. Hand hygiene is recommended before and after resident contact.
Staff Considerations
- All staff must complete competency regarding appropriate use and donning and doffing technique for PPE.
- Staff must be provided with training and resources to ensure that they change their gown and gloves and perform hand hygiene in between care of residents in the same room.
- Incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education.
Implementing Contact versus Enhanced Barrier Precautions
This table only applies to MDROs, not all pathogens that may require use of transmission-based precautions.
| Resident Status | Contact Precautions | Use EBP |
|---|---|---|
| Infected or colonized with any MDRO and has secretions or excretions that are unable to be covered or contained. | Yes | No |
| Infected or colonized with a CDC-targeted MDRO without a wound, indwelling medical device, or
secretions or excretions that are unable to be covered or contained. |
No | Yes |
| Infected or colonized with a non-CDC targeted MDRO without a wound, indwelling medical device, or secretions or excretions that are unable to be covered or contained. | No | At the discretion of the facility |
| Has a wound or indwelling medical device and secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with any MDRO. | Yes unless/until a specific organism is identified | Yes if they do not meet the criteria for contact precautions. |
| Has a wound or indwelling medical device without secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with any MDRO. | No | Yes |
Examples of secretions or excretions include wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and pose an increased potential for extensive environmental contamination and risk of transmission of a pathogen.
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