All right, well, welcome everyone.
Thank you for joining us for the May 22nd, 2024 Long Term Care
Town Hall: Understanding Enhanced Barrier Precautions.
We are very thankful for the support and collaboration of the
Centers for Disease Control and Prevention's Project First Line,
which has enabled us to provide this webinar to you all as
quickly as possible after learning about the recent EBP
enforcement memo.
I'm Commander Kara Jacobs Slifka.
I'm a medical officer with the
CDCs long term care team.
I lead our Long term care team here within the Division of
Healthcare Quality Promotion.
I'm really excited to introduce the two members of the Long term
care team who we will be presenting this webinar, Doctors
Bola Ogundimu and Heather Jones.
Dr.
Ogundimu is a nurse infection preventionist and health
scientist.
In her role, she provides consultation and technical
assistance for implementing infection prevention and control
strategies in post acute and long term care settings in
collaboration with state and local health departments across
the United States.
Doctor Ogundimu currently leads work focusing on the
intersection between health disparities and infection
prevention.
Doctor Heather Jones serves as a Nurse consultant, having begun
her healthcare career as a registered nurse in acute care
and then as a family Nurse Practitioner working alongside
medical directors and staff in nursing homes.
In 2020, she received her doctorate in nursing practice
and began her public career public health career with CDC.
Doctor Jones provides infection prevention and control subject
matter expertise for post acute and long term care outbreak
responses and has presented at many local and national
conferences.
Doctor Jones is currently leading efforts for better
understanding the role of infection preventionists in long
term care settings.
right.
And I've already shared our disclosure, so I will not repeat
those.
Thank you everyone for joining us again today.
I'm going to now do a little bit of a presentation of the iceberg
effect and many of you that have been in our long term care calls
before as well as know anything about infection and colonization
and MDROs will be quite familiar with the iceberg
effect.
So to begin, when we think about the iceberg and we think about
the tip, this is the tip of the iceberg and this is what we see.
And so the tip of the iceberg is clearly visible to everybody and
it depicts what we already know or what we physically see or
know about a patient or a resident.
A MDRO infection is the tip of that iceberg.
And when a person has an MDRO infection, they have presence of
signs and symptoms in the resident or patients.
Or another way to look at this is if a person has a documented
infection or colonization with the MDRO and it is present in
their healthcare record.
So you see this and you know this.
It isn't a part of what we know as the larger unseen part.
What we don't see or we don't know.
And this is the large portion that's hidden below the surface.
This is what we often discuss when talking through a MDRO
colonization or multi drug resistant organism.
A MDRO colonization is when a resident has the presence of an
MDRO that is not causing signs and symptoms or it's not present
in their medical record or their healthcare records.
So you do not know that they are colonized with the MDRO and
Here's the whole picture.
So when we think about the whole picture, this is where the
prevention strategies come into play.
If you don't see or know the large unseen portion of MDRO
colonization, and you're only aware of the few residents who
have a known MDRO infection or colonization in a nursing home,
you must have prevention strategies in place to stop the
spread of all unknown MDRO's.
A recent study found that only a small portion of residents in
the study were already known to have an MDRO, but when they
began to actively look for MDROs in these residents of
these nursing homes, they actually found that one out of
every two were found to have the MDRO.
So we wanted to establish the basis of why there is an
importance for having prevention strategies including enhanced
barrier precautions.
And now I'm going to turn it over to Bola who is going to be
speaking a little bit more about those.
Thank you so much Heather.
And so for exploring again like a rationale as well as a or
exploration of enhanced barrier precautions as noted in the next
slide.
So we have enhanced barrier precautions as an infection
prevention and control strategy that is really designed to
reduce transmission of multi drug resistant organisms
otherwise known as MDROs in our nursing homes specifically.
So EBP enriches enhanced barrier precautions.
It involves again the use of gown and gloves that is focused on
resident care activities most likely leading to the spread of
MDROs in our nursing home facilities.
Next slide please.
So as a refresher, going through the different types of
precautions that we have, starting out with the standard
precautions, we recognize the standard precautions a pair or
apply to the care of all residents where the use of PPE
is really based on anticipated exposure to blood, body fluids,
secretions as well as excretions.
So for instance, gloves are recommended when we someone a
healthcare personnel will be in contact with blood or
potentially infectious materials, mucous membranes as
well as non intact skin or contaminated equipment.
If it's anticipated that that interaction will occur. Again
going that is standard precautions.
And so in contrast or or sometimes in complements with
their enhanced barrier precautions, which is the use of
gown and gloves beyond the anticipated blood and body fluid
exposure.
And again, enhanced barrier precautions focuses on gowns and
gloves that are used during high contact resident care activities
that have been shown to result in the to decreased transfer of
MDROs to hands and clothing.
So again, to prevent transfer of MDROs to the hands and
clothing of health care personnel, even if blood and
body fluid exposure is not anticipated. Point to note is
that standard precautions could still apply even when you're
using an EBP.
So for instance, if it's anticipated that for a procedure
there will be splashes or sprays or interactions with the
residents, if splashes or sprays are anticipated during high
contact resident care activities, face protection
really should be used in addition to the gown and gloves.
So essentially standard precautions plus enhanced
barrier precautions where you anticipate that there's another
level of body fluid exposure.
Next, we have contact precautions and that actually
requires the use of gown and gloves on every single entry
into a resident's room regardless of the level of care that is
being provided to the resident.
So contact precautions are generally intended to be
time limited and when they're implemented, there should be a
definitive plan or at least a possible plan for
discontinuation or de-escalation of the contact precautions.
And then the resident is actually given a lot of times
dedicated equipment, the stethoscope, blood pressure
cuff, sometimes dynamaps and is placed in the private room
setting specifically for contact precautions.
And then we also say when private rooms are not available,
some residents typically we say grouped like residents together.
so some residents may be cohorted or grouped together
and then also residents of contact precautions should be
restricted to their rooms except for medically necessary
care and they also restricted some participation of group
activities.
So again, those are the contrast between standard precautions,
enhanced barrier precautions and contact precautions.
And just reiterating again, enhanced barrier precautions
will be gown and gloves used, but if you anticipate there's
additional like body fluid exposure, then standard
precautions would also be used in addition to enhanced barrier
precautions. Next slide.
So at a minimum, enhanced barrier precautions are intended to be
used for residents colonized or infected with MDROs targeted
by the CDC.
We've often gotten questions about what do we mean by CDC
targeted MDROs.
So I'll be going over that the next couple of seconds.
So for the next slide, So what do we mean by a targeted MDRO?
So essentially targeted MDRO's are germs that are resist
resistant to most or all available antimicrobial agents
and have the potential to spread widely and intensive public
health actions are typically required to slow the spread of
targeted MDROs.
And next slide we have a couple of examples.
So just off this list on the slide we have
Pan-resistant organisms which I mentioned earlier as well as carbapenemase
producing carbapenem-resistant Enterobacterales and then also
carbapenemase-producing carbapenem-resistant
Pseudomonas species and also Carbapenemase-producing
carbapenem-resistant is the Acinetobacter baumannii which
also some is known as crab and then Candida auris is another
example.
So next slide, it is important to note that in addition,
residents should have MDRO prevention strategies in place
for residents at high at an increased or higher risk of
being colonized or already colonized or infected.
And we would be using EBP for residents with indwelling
medical devices essentially as an MDRO prevention strategy
that could be used or that may be used for this group of
residents with increased risk.
So the first increased risk would be residents with
indwelling medical devices such as indwelling foley catheters or
indwelling urinary catheters, tracheostomies, ventilators as
well as central venous catheter like PICCs or ports.
And then for the purposes of EBP, we had also added midline
catheters in addition to that.
So next slide, we have also EBP may be used for residents that
have a wound.
So we got a lot of questions about wounds.
Like what?
What do we mean by wounds?
So we're not talking short term wounds that you can apply
band-aid kind of dressing on.
We're talking more chronic wounds like pressure ulcers or
diabetic foot ulcers as well as chronic venous stasis
ulcers as we recognize that chronic wounds are risk factors
for MDROs.
And so the other next slide we have is just thinking through
our EBP versus contact precautions.
So we've often gotten questions about, well who needs contact
precautions instead of enhanced barrier precautions.
Still to answer that question again, recognize that EBP is
specific for MDROs prevention specifically in nursing homes
and so Appendix A of the isolation guidelines would still
apply for other pathogens.
So in your facility or in any facility, specifically nursing
homes, if a resident, for instance, has certain conditions
where there might be possible transmission if not contained,
then contact precautions should be implemented.
So those examples would include for a facility that has
residents, for instance, with acute diarrhea.
For those residents, contact precautions will be in place as
well as residents that have draining wounds that can't be
contained or covered like they'd have weeping wounds, contact
precautions would be implemented.
And then also if there are conditions where the
resident is unable to contain their excretions, for instance,
for cases like C diff where or even norovirus where they might
have explosive diarrhea, then contact precautions would be
implemented.
And again, it's just secretions or excretions that can't be
covered or contained. Next slide.
So we also have situations where as I indicated earlier, other
situations outside of not being able to contain or cover whether
it's a wound, weeping wound or on excretion.
Also have situations where if a facility has a suspected or
confirmed MDRO outbreak in working together with the public
health department and often times it is directed by the
public health department or public health authorities
investigations, that contact precautions is in place again
for a time limiting period.
And this is generally intended again to be time limited.
And when implemented there should be a plan for
discontinuation or de-escalation.
And also not all MDRO outbreaks may need the use of contact
precautions.
Again, we encourage you to work with your public health
department to really go through with different steps of your
outbreak investigation in collaboration with them.
Next slide.
So we've often gotten these questions regarding what the CDC
defines or you know it gives examples of high contact
resident care activities.
So those activities include, first off, things like dressing,
bathing or showering, as well as transferring the residents one
spot to the other from bed to chair and vice versa.
And also providing hygiene and changing bed linens as well as
changing sheets or assisting a resident with toileting as
well as handling their indwelling medical device.
And also if we're gonna be assisting with maintaining their
indwelling medical devices, that gowns and gloves would be needed
for those circumstances.
And again, when we talk about wound care, as I illustrated
earlier, we don't necessarily need the shorter lasting
Band-Aid wounds.
We're talking more chronic wounds and a lot of times we
often say that those resident care activities that are shown
on this slide, the high contact resident care activities should
be bundled as much as possible.
So if you're doing AM care, it is important to consider what
else you can have in place as maybe being able to group
together the different activities that can be done.
And the next couple of slides will show certain examples of
what can be done for facilities while they're bundling different
resident care activities.
Next slide.
OK.
So again, many of the high contact resident care activities
are typically bundled inside the room as part of AM or PM care as
I noted earlier.
So for instance, on the left side of the slide that is
circled in in red, activities such as helping the resident use
the toilet or toileting, helping them getting freshened up as
well as helping them get dressed or change bed linens and
transferring the resident from bed to chair.
Vice versa can be bundled together during one interaction
with the resident.
So otherwise we call it AM care in some instances.
In another instance on the right activities such as assessing
wound care, dressing or changing wound dressings as well as
performing skin assessment and also assessing
their feeding tubes or giving medications through their
feeding tubes also can be bundled together or can be
provided at certain intervals rather than just using a single
entry into that resident’s room.
So next slide we have again EBP is generally not necessary for
brief minimal touch interactions with the residents.
And also if the healthcare personnel is not
necessarily touching the resident or environment inside
the room, then EBP is not needed.
So for instance, if there is anticipated isolated foaming of
the residents pair that is not otherwise bundled with other
high contact resident care activities, then that
interaction would not necessarily mean gown and gloves,
essentially no EBP for that only isolated instance.
Next slide.
So again as to why we have EBP being recommended, we've looked
at multiple studies over the years and over the next couple
of slides we wanted to share different studies that have
looked at high contact resident care activities that have
resulted in the highest spread of MDROs.
So as you can see on this slide with the bars, the highest risk
activities included those where we recommend gown and gloves to
be used in the current EBP recommendations.
Again, these slides will be available to everybody after the
town hall. Next slide.
We also showed similar results with other studies that others
have done, really indicating the highest risk activities that
that force the most MDRO spread.
Again, the importance of having data from these nursing homes
cannot be overstated.
So observations of the types of care activities that are
performed in nursing home residents and which activities
are found to be the highest risk of spreading MDROs to
healthcare personnel, which could then spread to other
residents and even themselves really directly influenced by
EBP guidance.
And then we have the next slide,
So with the previous studies that I had noted earlier, again
really these high contact activities have the most spread.
But this particular slide that, this particular slide
denotes like how targeted gown and glove use also known as EBP
or enhanced barrier precautions successfully reduced the
transmission of MDRO.
So this study in particular demonstrated that nursing homes
were able to successfully identify residents with risk
factors for MDROs as I indicated earlier and also
obtained an excellent adherence to the focus use of gown and gloves
meaning EBP by healthcare personnel during these
high contact resident care activities.
And again these results that we have on the slide showing on the
bar indicate that EBP was an evidence based approach for
preventing the transmission of MDROs and additional related
studies are ongoing right now to continue to support our ongoing
understanding of the most of the most effective approaches to
preventing MDRO transmission in nursing homes.
So again, nursing homes have successfully identified who met
EBP, as well as, successfully been able to have adherence to gown
and glove use within their different facilities.
And so we have had our partners share the possibility of having
EBP implemented and the successes that our partners have
found as well as challenges that our partners have been able to
identify with implemented EBP at our nursing homes.
So with that said, I will hand over to Heather to talk about
why we need EBP as part of the MDRO prevention strategy.
Thank you, Heather.
Thank you so much, Bola.
I'm now going to discuss why it is needed.
Why do we need enhanced barrier precautions as part of an MDRO
prevention strategy?
First, nursing home residents are at the highest risk and
higher risks for not only having but getting MDRO colonization or
infection.
A majority of people who live in nursing homes are older, and as
a person ages, the body is less able to fight infection as they
would have been when they were younger.
Most have multiple comorbid conditions such as high blood
pressure, chronic kidney disease, or chronic respiratory
conditions.
Nursing home residents also depends on many of the staff
members to help them with caring for themselves, whether through
physical or cognitive limitations.
There is also a high social context within nursing homes and
multiple interactions occur between both residents and
staff.
Other higher risk factors that affect the likelihood of MDRO
spread is that a lot of the residents have had a recent or a
long hospital stay, they have wounds and in dwelling medical
devices.
A majority of nursing homes in the United States continue to
have multi resident rooms with up to four residents together in
one room.
There is also a continued overuse of antibiotics in our
nursing home residents which all can place them at a higher risk
of acquiring a MDRO.
So how can you be successful in implementing enhanced barrier
precautions?
It starts with robust and foundational prevention
strategies along with enhanced barrier precautions from cleaning
your hands to environmental cleaning and disinfection,
auditing practices and good communication.
First, very foundational information, but also very
important is to emphasize cleaning your hands, especially
before and after any care with a resident or patient or after
using or touching equipment in their environments.
Alcohol based hand sanitizers continue to be the preferred
method for cleaning your hands when they are not visibly dirty
and when your hands are visibly dirty,
clean your hands with soap and water and make sure that staff
has easy accessibility to the products they need to clean
their hands appropriately.
Next up is cleaning and disinfection.
Although many times seen as a primary duty of Environmental
Services staff members, cleaning and disinfection is important
for everyone to take part in.
Make sure high touch surfaces are cleaned and disinfected at
least daily and reusable equipment must be cleaned and
disinfected after each and every use.
Work with others in your community or facility to reduce
the number of cleaning and disinfection products you were
using while also ensuring the most appropriate hospital grade
products are being used and develop, maintain and use a who
cleans what list so that everyone on the team knows who
is responsible for which items.
Next is a brief discussion about auditing.
Auditing is your way of knowing if the education you have
provided to staff is being implemented and done
appropriately.
This should happen with all aspects of infection prevention
and control and include hand hygiene audits.
How well are PPE being taken off and put on?
Also looking at the cleaning and disinfection practices and not
only at those high touch locations but also daily and
terminal room cleans.
And audit your communication practices of the staff members
and as important is to share the feedback with your staff so they
know if there are opportunities for improvement and
acknowledging when challenges have been overcome.
Communication is the final piece of the prevention strategies I
wanted to discuss.
Communication should not only occur within the units of your
facility but also with outside partners.
Find and use a communication tool that works for everyone
across the community and make sure pertinent information is
shared as we are all connected.
Here are a few more tips to help you with the initial
implementation of EBP in your facility or facilities.
Provide initial and ongoing education to everyone who comes
into, works in, or lives in your community or facility.
Include all staff and all shifts.
Don't forget to provide education to the overnight
shifts and the weekend staff.
Create a robust rollout plan and use the tools that have been
developed.
Don't reinvent the wheel.
Many of the tools can be customized so you can tailor
them to your unique community.
Start by using the CDC Pre Implementation tool and make
sure to 1st identify a method which residents need EBP
initiated and then how best to maintain this record.
Now I want to show you just one example of what can happen when
any one of these prevention strategies are missed.
You have an acute care hospital which has a known MDRO outbreak
and patient A and patient B arrive for care.
During patient A stay, they acquire a MDRO, then patient A
and patient B transfer out to a long term acute care hospital
for further care.
Patient A brings that MDRO along with them. Well through poor
preventive practices.
Patient B now also acquires or gets the MDRO. Well,
after a little bit of time they part ways and patient A goes to
a skilled nursing facility or SNF 1 and takes the MDRO
along with them.
Patient A or resident now Resident A meets Resident C and
Resident D through bad practices and not following appropriate
and adequate prevention practices,
now Resident C and Resident D also have acquired or gotten the
MDRO.
And let's not forget Resident B. Resident B went to SNF 2 and
took the MDRO with them as well.
So then Resident B meets Resident E and Resident F in
that SNF 2. Through poor prevention practices,
once again, Resident E and Resident F acquire or get the
MDRO as well.
So due to prevention practices not being followed, such as a
lapse and communicating MDRO status, perhaps staff weren't
cleaning their hands after providing care to the patient or
residents once they got to the SNF.
Maybe they didn't put them on enhanced barrier precautions and
they had an indwelling medical device that necessitated them
being on it.
Someone didn't clean and disinfect as was required or
there's an absence of auditing in any one of these locations.
So what happened was that what was only one MDRO colonization
or infection at the acute care hospital has now become six MDRO
colonizations or infections across two separate long term
care facilities.
And as I shared, this is only one brief example of how MDROs
can spread across healthcare communities. Which brings me to
my final slide and that is to emphasize enhanced barrier
precautions being a method to balance safety of the residents
with maintaining the residents quality of life.
We know MDROs are common in nursing homes and the MDRO
colonization can lead to serious infections and even death in our
residents.
Implementing strategies such as enhanced barrier precautions can
prevent the spread of MDROs while considering the unique
aspects of nursing home care and socialization.
While in other healthcare settings, the answer is to use
contact precautions for MDRO infection or colonization.
A nursing home is not an appropriate setting for long
term prevention of MDROs with contact precautions as it would
see residents not being able to maintain a good quality of life
because they would be restricted to the rooms except for
medically necessary care, as well as being restricted from
being able to participate in group activities.
Enhanced Barrier precautions is a prevention strategy that
balances each of these together.
Prevention of MDRO spread, maintaining resident safety and
improving a resident's quality of life.
As we shared previously, the slides will be made available
after our webinar and town hall.
And these are a few of the links updated since our recent
Clean Slate CDC.gov updates.
And these provide some of our educational videos that are
available on this slide.
And then these are enhanced barrier precaution tools that
can help you with implementation as well as letters that you are
able to customize for residents, families, staff and nursing home
leadership.
We've also developed posters and a pocket guide that can help you
with the staff development and ongoing education.
I will now turn it back to Kara who will moderate for any
questions.
Thank you.
Thank you so much.
I want to, I want to give a special thank you to Doctor
Ogundimu and Doctor Jones for walking us through this webinar.
I have been taking note of the questions that are coming in.
We will do our best to try to get to as many of those as
possible.
I may combine some of them and try to give an answer that will
hopefully help with the related questions that we are seeing
coming in.
So to start, I think we have had a couple of questions that have
been specific to wounds.
So I think let's go ahead and start with clarifying what
wounds would be an indication for enhanced barrier
precautions.
Thanks, Kara.
And that's a pretty great question.
So the guide, our EBP guidance describes that all
residents with rooms would meet the enhanced barrier precautions
guidance.
However, the intent again of our EBP guidance is to focus on
residents that have a higher risk of acquiring MDRO over a
long period of time, so not just hours, right.
And so within the enhanced barrier precautions, frequently asked
questions or FAQs, we actually expand more on describing the
focus on residents with chronic wounds and not the short term
wounds like the band-aids, quote and quote ones, as I noted
earlier.
So it's more chronic wounds that include your pressure ulcers as
well as diabetic foot ulcers and chronic venous stasis ulcers.
Thank you.
So thank you.
So the focus being on chronic longer lasting wounds and then
you started to mention are there wounds that are not considered
to be an indication for EBP?
Yeah, thanks, Kara.
So yeah, your shorter lasting wounds as I indicated earlier,
the band-aid wounds or the skin grades or skin tears that are
again like cover like with the small dressing or shorter period
of time or anything similar in terms of the dressing would
not be an indication for EBP.
Again, it's a shorter time kind of route.
And so for we did actually have fielded questions from different
facilities as well as HAI programs about healing post op
surgical wounds and that specifically healing post op
surgical wounds would not be an indication for EBP.
Thank you.
And that came up that has come up a few times in the, the
Q&A on the webinar today.
So, you know, while there isn't a definition for the exact
amount of time that a wound must be present to become colonized,
we recognize that the longer a wound is present, the more
concern we have that these wounds may become colonized with
an MDRO.
And so in situations where underlying medical conditions
lead to chronic poorly healing wounds, our concern level
increases that those may become colonized with an MDRO.
So I do also because again, a few questions have come up.
I think this is related to wounds.
There are a few questions about ostomies specifically. Do we
are those considered to be wounds?
Thanks for that excellent question, Kara.
No ostomies.
And when I talk about ostomies, I'm referring to like
colostomies and ileostomies.
These are not considered to be wounds for enhanced barrier
precautions.
And to help clarify this commonly asked question, we have
also updated our enhanced barrier precautions frequently
asked questions page to specifically address ostomies so
that you'll have a way to refer back in case you have questions
that are brought up.
Now, ostomies are not considered to be wounds, but for EBP
purposes, but if they have an indwelling medical device, so
like if you're thinking about a tracheostomy tube or a
percutaneous nephrostomy tube, those would be an indication for
EBP because there's now a component that's communicating
internally and externally, which places them at a higher risk of
getting an MDRO or even acquiring one.
Thank you, Heather.
One of the other common, one of the other common questions I've
seen about throughout the chat has been asking about physical
therapy, asking about therapy, you know, in a therapy gym there
there have been numerous questions that have brought up
therapy and wanting us to clarify a little bit more here.
And we definitely recognize that physical therapy encompasses a
wide range and not just physical therapy, occupational therapy,
therapy activities.
They there are a wide range of activities and they are not
specifically called out as high contact resident care activity.
So can you can, can you talk a little bit about whether
physical therapy or therapy is considered to be high contact?
Should therapists be using PPE?
Yeah.
Thank you so much, Kara.
So depending on the activity, therapy may be considered a high
contact resident care activity.
And again, we see therapists should use gown and gloves when
when working with residents on EBP and the therapy gym that's
ideal or in the resident’s room if they anticipate having that
prolonged to those body contacts where transmission of MDROs
to the therapist clothes is certainly possible.
And so as a follow up to that, what if the therapy can't be
performed in the therapy gym or in the resident’s room?
Or as some examples in the chat have shared, what if the
resident needs assistance walking from their room to the
therapy gym or in the hallways?
Is it OK to use PPE in the hallways?
Yeah, that's a great follow up question.
So EBP is it really should not limit a resident's ability to
continue their medical therapy that is critical, right?
And so while the use of gowns and gloves is generally
discouraged in the hallways and other common areas, there may be
individual circumstances like therapy that has to occur
outside the resident’s room or outside the therapy gym that
would prompt an evaluation for the need of PPE outside of the
room or the gym.
Really depending on the level of assistance or close contacts
that the therapist or anybody helping out with therapy will be
happening with the residents.
And I also wanted to add a comment here that we understand
and we know that there is a lot of gray area when we talk about
these situations and when it comes to infection prevention in
general and not just with the practices of enhanced barrier
precautions.
Because we understand that even the most seasoned infection
preventionists are going to be faced with new different
situations and you will need to evaluate those situations based
on your expertise as they arise and then make the best
determinations based on best practices for both the residents
and the healthcare worker safety.
Thank you both.
I want to shift the topic a little bit to talk about
midlines because there are multiple questions that have
come in during the webinar specific to midlines or midline
catheters and asking for more explanation in terms of are
these considered to be indwelling medical devices for
the purposes of enhanced barrier precautions?
Yeah, thank you so much for another great question.
So yes, midlines in addition to central venus catheters, so your
CVCs that includes your ports or PICC lines are considered
indwelling medical devices for the purposes of EBP.
Yes. And thank you, Bola, can you expand upon that a little bit?
Some of the questions have asked since peripheral IVs are not
included as indwelling medical devices for EBP and you know,
can you share a little bit more about why midlines are
considered an indwelling device?
Yeah, great follow up.
So more importantly, residents who have midline catheters as
part of their medical therapy, often complex, right, tend to be
residents with additional risk factors for MDRO
colonization.
So similar to central venous catheters, PICC supports these
midlines may remain in place for an extended period of time,
again longer period of time, often up to four weeks or more
and thereby increasing the risk of an infection or MDRO
acquisition.
Thank you.
Thank you, Bola.
I'm seeing numerous questions asking for us to expand a little
bit more on the brief contact that was mentioned
during the webinar.
So are can you expand or one of you able to expand a little bit
more on what those situations might be, you know, particularly
inside of a resident’s room who's on EBP where limited enough
contact occurs between the resident and nursing home staff
that PPE might not be indicated?
Absolutely, Kara, thank you.
So we've been asked about situations.
One example is like going into the resident’s room and helping
them put on a sweater or going in to just do a minimal transfer
and it's brief contact that occurs.
Or even if you're individually going in to brush someone's
hair.
These are examples of activities that Bola shared previously.
They're constantly bundled together as part of
morning or evening care rather than occurring as those multiple
isolated interactions throughout the day.
When bundled together, it would be an indication to wear a gown
and gloves because you're having that prolonged contact care with
the residents while you're bundling it together.
But if you're in there for an isolated activity, you're having
a short brief interaction contact with the resident,
this would not generally necessitate the need for using
gown and gloves.
Thank you.
So similarly, while the presence of so similarly, I want to ask a
little bit about this question related to an indwelling medical
device.
So we know that indwelling medical devices are a major risk
factor for being colonized with or being at risk for becoming
colonized with an MDRO.
Can you talk a little bit more about use of medical devices
that might only involve limited physical contact between a
healthcare worker and a resident and the use of gloves and
gowns in in that type of situation?
Yeah, thanks, Kara.
I am happy to expand on that a little bit.
One example that I like to give is that say you have a staff
member that's going to pass medications through a feeding
tube.
And although this is only appropriate if the activity is
not bundled together with other high contact prolonged care
activities and there's no evidence of ongoing MDRO
transmission in the facility, the safest practice would be to
wear a gown and gloves for any care or use of an indwelling
medical device.
But facilities can define these limited contact activities in
their policies and procedures and educate healthcare personnel
so they can ensure consistent application of enhanced barrier
precautions when it comes to these brief interactions that
occur.
Thank you.
I want to comment or I want to ask you to comment also on PPE
storage.
So, so speaking about PPE, where, where should PPE be
storage stored with EBP?
Yeah, Thanks, Kara.
This question has come up often.
CDC continues to recommend that PPE is located immediately
outside of the resident’s room or at the entry to the resident’s
room.
And we've discouraged the practice of storing the PPE in
the room primarily because there is a risk of contamination.
This is one specific question where many of you have pointed
out previously that CDC and CMS have responded slightly
differently.
However, our key message aligns, PPE should be readily available
for a staff member to use when they are planning to provide
high contact resident care and whether stored inside or
immediately outside of the resident’s room, the facility
should make every effort to avoid contamination of that PPE.
Thank you, Heather. Now I know we are, we are nearing the end of our
time, but I did see that there were a couple of questions
specifically asking about the studies that were shared.
And these are available in the the there or resources that we
will include with these slides.
And they are also available on the CDC EBP web page.
So you can take a look and review in more detail.
I did want to ask the Washington State Department of Health had
shared with us an analysis done looking at cost effectiveness of
EBP Bola very quickly in the last minute.
Are you able to share briefly what they've learned?
Sorry, yeah.
So with Washington State HAI program and I don't see them on
the call, but that's OK.
So they had done a cost analysis of skilled nursing facilities
using enhanced barrier precautions, looking at their implementation
like how much it costs versus the cost of contact precautions,
implemented contact precautions and the C. auris outbreak
investigation.
And the specific nursing home that they looked at was 100
beds.
And they had ten different residents essentially that have
foley catheters that would have met the enhanced barrier
precautions implementation criteria.
And they also learned that if they looked at residents needing
the indication for contact precautions.
That again, looking at the cost, the aggregate costs, they
determined that they would need an RN to provide six contact
care activities per resident per day with the CNA providing 4
contact activities per resident per day and cleaning products,
also for C. auris that have to be specifically noted with the kill
claim as well as the germicidal bleach wipes for C. auris,
and also screening time for staff or resident depending in
terms of what residents were C. auris positive.
So they overall determined that for that specific instance in
implementing contact precautions, they would have to
spend about $945 per residence in that isolation room.
And again, like I don't see Carolyn on the call, but if you
guys would like more information about their study, please feel
free to reach out to your HAI program, but it was shared by
Washington State HAI program.
Thank you, Bola.
And I want to thank the audience again for joining us today.
Thank you to our speakers, Doctor Bola Ogundimu and Doctor
Heather Jones, greatly appreciate you sharing with this
audience today.
And we will be working on putting all of this information
on the web so that you are able to refer back to us.
Thank you so much again for joining us.
And just real quick, Kara, I wanted to respond.
There's been a lot of people that are asking about the link
for the FAQs.
The best that I can share now is if you will go into your search
engine and type CDC Enhanced Barrier precautions.
You will be able to get to our primary slide and you scroll all
the way down and then it will take you to a link that says
frequently asked questions.
That is one of the best areas to find more defined answers to
many of the questions that have been asked today.