Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes

These FAQs were created to address questions about Enhanced Barrier Precautions as defined in the CDC guidance “Implementation of Personal Protective Equipment (PPE) in Nursing Homes to Prevent Spread of Novel or Targeted Multidrug-resistant Organisms (MDROs)

Definition and scope of Enhanced Barrier Precautions

  1. Do Enhanced Barrier Precautions replace/supersede the recommendations in the CDC Guideline for Isolation Precautions (2007) and the Guideline for the Management of Multidrug-Resistant Organisms (MDRO) in Healthcare Settings (2006)?
    No. This supplemental guidance is intended to clarify expectations for personal protective equipment (PPE) use and room restriction in nursing homes for preventing transmission of novel or targeted MDROs, including as part of a public health Containment Response.  The CRE Toolkit and CDC website addressing infection control recommendations for Candida auris are being updated to reflect this new guidance for nursing homes.  Future updates are anticipated to address application of Enhanced Barrier Precautions outside of a Containment Response. However, facilities may choose to apply Enhanced Barrier Precautions for residents infected or colonized with, or at-risk for acquiring other epidemiologically-important MDROs.

  2. Are Enhanced Barrier Precautions recommended for healthcare settings other than nursing homes, such as long-term acute care hospitals (LTACHs)?
    At this time, CDC does not have guidance for implementation of Enhanced Barrier Precautions in other healthcare settings.

  3. What is the evidence that Enhanced Barrier Precautions are effective at preventing MDRO transmission?
    In the Targeted Infection Prevention (TIP) intervention study1, the implementation of preemptive barrier precautions (use of gowns and gloves) during daily care of residents with indwelling devices, as part of a multifaceted program to reduce MDRO spread in nursing homes, demonstrated a 23% reduction in MDRO prevalence among residents with devices. The findings provide support for use of barriers during high-contact care activities for high-risk residents as a means to disrupt MDRO spread.
    During public health Containment Responses, screening activities often identify additional residents colonized with a novel or targeted MDRO who were previously unknown to the facility. The majority of these MDRO colonized residents have one or more exposures, like an indwelling device, that increase their risk for transmission. Although many of these colonized individuals are asymptomatic (i.e., no signs or symptoms of infection) and would not be placed in Contact Precautions based on most nursing home policies, they remain a source for ongoing transmission to other residents in the facility. Based on the experience in the TIP intervention study, the use of gowns and gloves during the high-contact care of these high-risk residents (Enhanced Barrier Precautions) has the potential to disrupt transmission in a less restrictive manner than prolonged placement in Contact Precautions for asymptomatic carriers. In addition to implementing Enhanced Barrier Precautions, facilities working with public health programs should also be addressing other infection prevention practices such as increasing adherence to hand hygiene and improving the cleaning and disinfection of shared medical equipment.

     

  4. How did CDC choose the high-contact resident care activities described in the guidance?
    The high-contact resident care activities described in the guidance were chosen based on hundreds of observations of care in nursing homes 2,3 that evaluated the potential for antibiotic resistant bacteria to contaminate the hands and clothing of healthcare personnel.  Those activities that demonstrated the highest risk for transfer to hands and clothing were included in the CDC guidance.

  5. How are Enhanced Barrier Precautions different from Standard Precautions?
    As part of Standard Precautions, use of PPE is recommended based on the “anticipated exposure” to blood, body fluids, secretions, or excretions.  Enhanced Barrier Precautions expands use of PPE beyond blood and body fluid exposures. This includes recommendations to use PPE for high-contact resident care activities that have been demonstrated to result in transfer of MDROs to gowns and gloves of healthcare personnel even if blood or other body fluid exposure is not anticipated.

  6. How are Enhanced Barrier Precautions different from Contact Precautions?
    Contact Precautions require the use of gown and gloves on every entry into a resident’s room, regardless of the level of care being provided to the resident. The resident is given dedicated equipment (e.g., stethoscope and blood pressure cuff) and is placed into a private room. When private rooms are not available, some residents (e.g., residents with the same pathogen) may be roomed together. Residents on Contact Precautions should be restricted to their rooms except for medically necessary care and restricted from participation in group activities. Because of these restrictions, placement in Contact Precautions is intended to be time limited.
    For Enhanced Barrier Precautions, gowns and gloves are recommended when performing high-contact resident care activities. Residents are not restricted to their rooms and do not require placement in a private room.  Because Enhanced Barrier Precautions do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be a longer-term approach to managing individuals colonized with targeted pathogens.

     

  7. Why does the Enhanced Barrier Precautions guidance focus on gown and glove use and not other important infection control measures (e.g., environmental cleaning) for preventing MDRO transmission in nursing homes?
    While this guidance focuses on gown and glove use, prevention of MDRO transmission in nursing homes requires much more than just proper use of PPE.  Adherence to other recommended infection prevention practices including performing hand hygiene, cleaning and disinfection of environmental surfaces and resident care equipment, proper handling of indwelling medical devices and care of wounds is also critical.  CDC and health departments continue to identify gaps in recommended infection prevention practices as part of on-site infection control assessments in nursing homes.  Examples include lack of access to alcohol-based hand sanitizer in resident rooms and other care areas; lack of access to EPA-registered disinfectants at the point of use; and failure to clean and disinfect shared resident care equipment after each use. During Containment Responses, facilities are provided guidance and support to improve all aspects of their infection prevention practices, in addition to implementing EBP.
    CDC has created a comprehensive, free, online training courseexternal icon for nursing homes addressing development and implementation of an infection prevention program.  Nursing homes are encouraged to have staff review relevant modules and to use the resources provided in the training (e.g., policy and procedure templates, auditing checklists) to assess and improve practices in their facility.

Application and duration of Enhanced Barrier Precautions

  1. Are Enhanced Barrier Precautions recommended for a whole facility or just the unit where a resident known to be infected or colonized with a novel or targeted MDRO resides?
    At a minimum, Enhanced Barrier Precautions are recommended for the unit or wing where a resident known to be infected or colonized with a novel or targeted MDRO resides.  In some facilities it may be advisable to implement Enhanced Barrier Precautions more broadly, based on the potential risk for those MDROs to spread to the other residents in the building (e.g., facilities that share staff and equipment across units).  Consulting with state or local public health partners and findings from on-site infection control assessments can help inform the scope of implementation.

  2. If a resident infected or colonized with a novel or targeted MDRO meets criteria for Contact Precautions (e.g., uncontained secretions or ongoing transmission is suspected), do I still need to put other residents on the same unit with indwelling medical devices or wounds on Enhanced Barrier Precautions?
    Yes.  Even if the resident colonized with a novel or targeted MDRO is placed on Contact Precautions, Enhanced Barrier Precautions are still recommended for other at-risk residents (i.e., those with indwelling medical devices or wounds) on the unit.

  3. Should nursing homes screen residents for novel or targeted MDRO carriage in order to implement Enhanced Barrier Precautions?
    There may be circumstances when screening cultures for presence of novel or targeted MDROs could be appropriate, especially when working with public health. However, screening to determine a resident’s MDRO status is not recommended solely for the purpose of implementing Enhanced Barrier Precautions. Enhanced Barrier Precautions are intended to provide an approach for gown/glove use that is based on resident risk factors and type of care, rather than based on MDRO status, especially for residents at risk for acquisition (i.e., presence of indwelling medical devices or wounds). While the current guidance focuses on facilities caring for residents known to be colonized with novel or targeted MDROs, some nursing homes have elected to implement Enhanced Barrier Precautions more broadly (e.g., for all residents with indwelling medical devices or wounds), regardless of presence of a novel or targeted MDRO in their facility.

  4. If a resident does not have a history of a novel or targeted MDRO but does have an indwelling medical device or wound, should they still be placed on Enhanced Barrier Precautions?
    Enhanced Barrier Precautions are recommended for residents with indwelling medical devices or wounds who reside on units with residents known to be colonized with a novel or targeted MDRO. This is because devices and wounds are risk factors that place them at higher risk for carrying or acquiring an MDRO.  Because of this, some facilities have moved beyond the current guidance and elected to implement Enhanced Barrier Precautions for all residents in their facility with indwelling medical devices or wounds, regardless of the presence of a novel or targeted MDRO in their facility.

  5. Why did CDC expand Enhanced Barrier Precautions to include residents with wounds or indwelling medical devices, regardless of MDRO status?
    Indwelling medical devices and wounds are risk factors that place residents at risk for colonization with an MDRO.  Once colonized, these residents can serve as sources of transmission within the facility.  The Targeted Infection Prevention (TIP) intervention study1 demonstrated that the implementation of preemptive barrier precautions (use of gowns and gloves) during daily care of residents with indwelling devices reduced MDRO prevalence by 23% among all residents with devices and also found a decreased risk of MRSA acquisition.   The expansion of EBP for residents with wounds or indwelling medical devices is intended to protect these high-risk individuals both from acquisition and from serving as a source of transmission if they have already become colonized.

  6. Are Enhanced Barrier Precautions recommended for methicillin-resistant Staphylococcus aureus (MRSA)?
    Currently the CDC guidance on the use of Enhanced Barrier Precautions is focused on preventing the spread of novel or targeted MDROS, defined as pan-resistant organisms, Candida auris and carbapenemase-producing organisms (Enterobacteriaceae, Pseudomonas spp and Acinetobacter baumannii).  However, facilities may choose to apply Enhanced Barrier Precautions for residents infected or colonized with other epidemiologically-important MDROs based on facility policy.

  7. Are Enhanced Barrier Precautions recommended for residents with Clostridioides difficile infection or scabies?
    No.  Enhanced Barrier Precautions does not replace existing guidance regarding use of Contact Precautions for other pathogens (e.g., Clostridioides difficile, scabies, norovirus) and conditions in nursing homes.  Refer to Appendix A – Type and Duration of Precautions Recommended for Selected Infections and Conditions of the CDC Guideline for Isolation Precautions for a list of infections and other conditions where Contact Precautions is recommended.

  8. Do residents placed on Enhanced Barrier Precautions for a novel or targeted MDRO require placement in a single-person room?
    No. Single-person rooms (if available) should be prioritized for residents placed on Contact Precautions for presence of acute diarrhea, draining wounds, or other sites of secretions or excretions that are unable to be covered or contained. Residents on Enhanced Barrier Precautions may share rooms with other residents. However, facilities with capacity to offer single-person rooms or create roommate pairs based on MDRO colonization may choose to do so.
    When residents are placed in shared rooms, facilities must implement strategies to help minimize transmission 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.
    If there are multiple residents with a novel or targeted MDRO in the same facility, consider cohorting them together in one wing or unit to decrease the direct movement of healthcare personnel from colonized or infected residents to those who are not known to be colonized.

     

  9. How long should a resident remain on Enhanced Barrier Precautions?
    Enhanced Barrier Precautions are intended to be used for the duration of a resident’s stay in a facility. A transition back to Standard Precautions, alone, might be appropriate for residents placed on Enhanced Barrier Precautions solely because of the presence of a wound or indwelling medical device when the wound heals or the device is removed.

  10. May we stop using Enhanced Barrier Precautions if we screen the infected or colonized resident and they test negative for the novel or targeted MDRO?
    Residents colonized with a novel or targeted MDRO are intended to remain on Enhanced Barrier Precautions for the duration of their stay in a facility.  Because MDRO colonization is prolonged and follow-up testing to determine clearance may yield false negatives, CDC does not recommend routine retesting of residents with a history of colonization or infection with a targeted MDRO.

Implementation of Enhanced Barrier Precautions

  1. My nursing home is receiving a resident known to be colonized with a novel or targeted pathogen from an acute care hospital. The resident was on Contact Precautions in the hospital.  Do we need to continue Contact Precautions in our facility or may we use Enhanced Barrier Precautions?
    The resident should be maintained on Contact Precautions if he or she has acute diarrhea, draining wounds or other sites of secretions or excretions that are unable to be covered or contained or the facility is currently in the midst of an outbreak (i.e., there is evidence on ongoing transmission).   Contact Precautions may also be recommended by the health department in certain situations.  Otherwise, Enhanced Barrier Precautions would be appropriate for the management of this resident.

  2. Are gowns and gloves the only personal protective equipment (PPE) needed for the high-contact resident care activities described as part of Enhanced Barrier Precautions?
    Not necessarily.  Gowns and gloves are the minimum level of PPE required for these high-contact resident care activities.  However, as part of Standard Precautions, 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).

  3. What activities are included under “providing hygiene”?
    Providing hygiene refers to practices such as brushing teeth and combing hair.  Many of the high-contact resident care activities listed in the guidance are commonly bundled as part of morning and evening care for the resident rather than occurring as multiple isolated interactions with the resident throughout the day. Isolated combing of a resident’s hair that is not otherwise bundled with other high-contact resident care activities would not generally necessitate use of a gown and gloves.

  4. What is the definition of “indwelling medical device”?
    An indwelling medical device provides a pathway for pathogens to enter the body and cause infection because it enters the body and has components that communicate with the outside environment.  Examples of indwelling medical devices include: central lines (including hemodialysis catheters), indwelling urinary catheters, feeding tubes, and tracheostomies. Devices that are fully embedded in the body, without components that communicate with the outside, such as pacemakers, would not be considered an indication for Enhanced Barrier Precautions.

  5. The guidance advises using Enhanced Barrier Precautions for the “care and use” of indwelling medical devices. How is “care and use” defined?  Do I need to wear a gown and gloves if I’m just injecting a medication into a resident’s feeding tube?
    The presence of an indwelling device is a major risk factor for being colonized with or acquiring an MDRO.  Therefore, the safest practice would be to wear a gown and gloves for any care (e.g., dressing changes) or use (e.g., injecting or infusing medications or tube feeds) of the indwelling medical device. However, it may be acceptable to use gloves, alone, for some uses of a medical device that involve only limited physical contact between the healthcare worker and the resident (e.g., passing medications through a feeding tube).  This is only appropriate if the activity is not bundled together with other high-contact care activities and there is no evidence of ongoing transmission in the facility.  Facilities should define these limited contact activities in their policies and procedures and educate healthcare personnel to ensure consistent application of Enhanced Barrier Precautions.

  6. Are gowns and gloves recommended for Enhanced Barrier Precautions 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.  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 as part of morning or evening care.  This extended contact with the resident and their environment increases the risk of MDRO spread 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.

  7. Is Physical or Occupational Therapy considered a “high-contact” resident care activity?
    Therapists should use gowns and gloves when working with residents on Enhanced Barrier Precautions in the therapy gym if they anticipate close physical contact while assisting with transfers and mobility.
    As part of Standard Precautions, gowns and gloves should be removed and hand hygiene performed when moving to work with another resident.  Therapists should also ensure reusable therapy equipment is cleaned and disinfected after each use and surfaces in the therapy gym receive regular cleaning and disinfection.

     

  8. Should Environmental Services (EVS) or housekeeping personnel wear gowns and gloves when cleaning rooms of residents on Enhanced Barrier Precautions?
    The current guidance only addresses use of gowns and gloves for high-contact resident care activities. The research that was the basis for the current guidance did not evaluate risk of transmission of antibiotic-resistant bacteria to the hands or clothing of Environmental Services (EVS) personnel. However, changing linen is considered a high-contact resident care activity; gowns and gloves should be worn by EVS personnel if they are changing the linen of residents on Enhanced Barrier Precautions. Otherwise, gown and glove use by EVS should be based on facility policy and anticipated exposures with body fluids, chemicals and contaminated surfaces.  Gowns and gloves should be worn by EVS personnel when cleaning the rooms of residents on Contact Precautions.

  9. Does posting signs specifying the type of Precautions and recommended PPE outside the resident room violate Health Insurance Portability and Accountability Act (HIPAA) and resident dignity?
    No. Signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the resident.  To do this effectively, the sign must contain information about the type of Precautions and the recommended PPE to be worn when caring for the resident. Generic signs that instruct individuals to speak to the nurse are not adequate to ensure Precautions are followed. Signs should not include information about the resident’s diagnosis or the reason for the Precautions (e.g., presence of a resistant pathogen); inclusion of that information would violate HIPAA and resident dignity.
    CDC has created examples of signs that can be used by facilities to communicate information about Transmission-Based and Enhanced Barrier Precautions pdf icon[PDF – 1 page]. Facilities can use these signs or modify them to create signs that work for their facility.

     

  10. Can PPE used for Enhanced Barrier Precautions be thrown away in regular trash or does it need to go in the red bagged waste?
    You should refer to local and state regulations regarding disposal of medical waste.  The OSHA Bloodborne Pathogen Standardexternal icon uses the term “regulated waste” to refer to the following categories of waste which require special handling, at a minimum: liquid or semi-liquid blood or other potentially infectious materials (OPIM); contaminated items that would release blood or OPIM in a liquid or semi-liquid state if compressed; items that are caked with dried blood or OPIM and are capable of releasing these materials during handling; contaminated sharps; pathological and microbiological wastes containing blood or OPIM.   Based on this definition, most 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.  However, local or state regulations may be more restrictive than this federal standard.  So you should refer to those when making decisions.

References

  1. Mody L, Krein SL, Saint S, et al. A Targeted Infection Prevention Intervention in Nursing Home Residents with Indwelling Devices: A Randomized Clinical Trial. JAMA Int Med 2015; 175(5):714-23,
  2. Blanco N, Johnson JK, Sorkin JD et al. Transmission of resistant Gram-negative bacteria to healthcare personnel gowns and gloves during care of residents in community-based nursing facilities. ICHE 2018; 39:1425-1430.
  3. Roghmann MC, Johnson JK, Sorkin JD et al. Transmission of Methicillin-Resistant Staphylococcus aureus (MRSA) to Healthcare Worker Gowns and Gloves During Care of Nursing Home Residents. ICHE 2015; 36(9):1050-7.