Nursing homes must begin to use enhanced barrier precautions to prevent broader transmission of multidrug-resistant organisms and to help protect patients with chronic wounds and indwelling devices, the Centers for Medicare & Medicaid said Wednesday.
New guidance issued to providers and state survey agencies adds the use of personal protective equipment during high-contact care activities to its infection and prevention and control standards. The changes are effective April 1.
The new standards bring CMS regulations inline with Centers for Disease Prevention and Control guidance issued in 2022. The enhanced barrier precautions require the use of gloves and the donning and doffing of gowns in six high-contact activities, but the requirements are less stringent than existing contact precautions.
CMS in its guidance acknowledged that some nursing homes have been hesitant to use the CDC barrier precaution guidance because it could have limited the activities in which residents colonized with a multidrug-resistant organism could participate. Instead, some nursing homes have used the precautions only with patients that have an active infection.
CMS said more than 50% of nursing home residents may be colonized with an MDRO. Examples of the organisms targeted by CDC include:
- Pan-resistant organisms
- Carbapenemase-producing carbapenem-resistant Enterobacterales,
- Carbapenemase-producing carbapenem-resistant Pseudomonas spp.,
- Carbapenemase-producing carbapenem-resistant Acinetobacter baumannii, and
- Candida auris.
What’s required
The new recommendations include the use of EBP during high-contact care for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, “in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.”
“We note that facilities have some discretion when implementing EBP and balancing the need to maintain a homelike environment for residents,” the agency said in a memo. “Residents are not restricted to their rooms or limited from participation in group activities. Because EBP do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be 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.”
Enhanced barrier precautions should be employed when dressing, bathing, transferring, providing hygiene, changing linens, changing briefs and assisting with toileting. They’re also required for patients using a central line, urinary catheter, feeding tube or tracheostomy/ventilator or with any skin opening requiring a dressing.
The memo said the precautions would not necessarily be needed when performing transfers in common areas such as dining or activity rooms, where contact is anticipated to be shorter in duration. Facilities also 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.
The new guidance is being incorporated under the F880 Infection Prevention and Control requirements.
Implications for staff, facilities
Bruce Y. Lee, MD, a professor of Health Policy and Management at City University of New York and an MDRO researcher, has found that maintaining contact precautions when handling nursing home residents who are colonized with MDROs cannot only benefit that nursing home but also other nursing homes and hospitals.
“That’s because nursing home residents may frequently be transferred back and forth between hospitals, other healthcare facilities, and nursing homes,” Lee told McKnight’s Long-Term Care News Thursday. “If such residents carry such MDROs, they can in turn cause outbreaks in all of these places. … Such infections could have significant health effects and be life-threatening as well as result in added medical costs.”
While using the additional personal protective equipment will likely drive up nursing home costs, Lee said the savings from prevented infections would outweigh those additional costs.
In a column for McKnight’s last month, infection preventionist Buffy Lloyd-Krejci, DrPH, CIC, praised the CDC guidelines as a “win-win” for residents and staff.
“EBP are intended to reduce the risk of MDRO transmission by healthcare personnel who may carry and spread MDROs on their hands or clothing, silent spreaders, while caring for high-risk residents,” she wrote. “Misconceptions about EBP have contributed to resistance toward implementation.”
Lloyd-Krejci said both residents and staff mistakenly believe that staff wearing gowns means that all residents being cared for have an infection. In many cases, however, the enhanced barrier measures are in place to keep the facility from having to isolate other residents and limit overall risk of spreading an MDRO.
She said education and differentiating enhanced barrier precautions from transmission-based precautions will be key to successful implementation.
It’s also important, she said, to remind residents, family and staff of what the new measures could prevent: a full-blown outbreak of an MRDO, such as C. auris, that requires screening and culturing, stricter isolation and limited visitation.
