long-term care infection prevention
By Cindy Fronning
Exploring Enhanced Barrier Precautions
What are Enhanced Barrier Precautions ? Where do they fit when considering Standard Precautions and Transmission-based Precautions ? How long have they been in effect ?
In the past several weeks , it has become apparent that many facilities across the nation are unaware of these precautions . With the COVID-19 pandemic starting shortly after the effective date of this guidance , it is plausible that it got lost in the shuffle of many new requirements and rules and reporting mandates as well as the number of residents with the infection , shortage of staff and lack of personal protective equipment ( PPE ). However , Enhanced Barrier Precautions are an important ingredient to stopping the spread of multidrug-resistant organisms ( MDROs ), so it seems prudent to discuss it . As of July 2019 , novel or targeted MDROs included :
● Pan-resistant organisms
● Carbapenemase-producing Enterobacterales
● Carbapenemase-producing Pseudomonas spp .
● Carbapenemase-producing Acinetobacter baumannii
● Candida auris
In an interview of Kara Jacobs Slifka , MD , MPH , and Nimalie Stone , MD , MS , physicians with the long-term care team in the Prevention and Response Branch within CDC ’ s Division of Healthcare Quality Promotion , addressed why MDROs pose such a threat in nursing homes , even more than in other healthcare facilities , They stated , “ MDROs , especially those for which we have limited antibiotic treatment options , pose a threat in healthcare because they colonize individuals for prolonged periods of time , silently spread , and cause invasive infections with high morbidity and mortality . As healthcare delivery keeps shifting away from hospitals , nursing homes are providing more care to medically complex and frail individuals who are more vulnerable to the harms from MDROs . The combination of the long lengths of stay , exposures to indwelling medical devices and antibiotics , and the increased dependence of nursing home residents contribute to the spread and acquisition in this setting .” 1
Infection precautions of some sort have been used since the 14 th century when ships were quarantined for 40 days out at sea to prevent the spread of Plague . By the early 1900s , some elementary practices were in place by using barrier gowns and the start of antisepsis such as handwashing and disinfection had begun . This was known as “ barrier nursing .” It wasn ’ t until 1970 that published guidelines were introduced and used . Throughout the rest of the 20 th century and the early years of the 21 st century , the guidelines changed and in 2019 enhanced barrier precautions were introduced . The COVID -19 pandemic brought home the need for diligent use of precautions and PPE . For this journey through the changes , see Table 1 on page 53 .
Using Contact Precautions often is a balancing act between
preventing MDRO transmission and residents ’ quality of life . Use of PPE and room restrictions leads to residents being isolated from staff and family and causes depression and physical function decline as witnessed during the current pandemic .
CDC states ,“ Focusing only on residents with active infection fails to address the continued risk of transmission from residents with MDRO colonization , which can persist for long periods of time ( e . g ., months ), and result in the silent spread of MDROs .” 2
CDC indicates there is growing evidence that using Contract Precautions in the current manner isn ’ t adequate to prevent MDRO spread .
Implementation of Enhanced Barrier Precautions is in the middle between Standard Precautions and Contact Precautions . PPE is used in certain circumstances but doesn ’ t require residents to be restricted to their rooms , thus providing the goal of reducing MDRO spread while maintaining residents ’ quality of life .
Perhaps to put Enhanced Barrier Precautions into some perspective we should discuss Standard and Contact Precautions .
Standard Precautions , as indicated earlier in Table 1 , are infection prevention practices that are used when caring for all residents regardless of infection or colonization status . These practices are based on the premise that all body , blood fluids , secretions and excretions ( except sweat ) may contain infectious pathogens that are transmissible . Proper PPE , hand hygiene , safe infection practices , respiratory hygiene and cough etiquette , environmental cleaning and disinfection , and disinfection of point of care equipment .
Contact Precautions are one of the Transmission-based Precautions that are used to prevent the spread of infectious pathogens that are spread via direct and indirect contact from the resident or resident environment . It requires the resident to remain in their room and are restricted from group activities . It is usually a short-term intervention and should have a planned discontinuation such as when symptoms are not evident or other criteria has been met .
Enhanced Barrier Precautions became effective on July 26 , 2019 . The interim guidance was updated and posted on that date . This update does not replace the existing Contact Precautions nor is it intended for acute-care or long-term care hospitals . It expands the use of PPE beyond Standard Precautions and calls for the use of gloves and gowns during high-contact activities where MDROs might be transferred to staff hands and clothes . This includes residents that are infected or colonized when Contact Precautions don ’ t apply .
Only the following high-contact resident-care activities are included in these precautions and require the wearing of gloves and gowns :
● Dressing
● Bathing / showering
● Transferring
● Providing hygiene
● Changing linens
Continued on Page 54