Study Highlights Successes and Challenges in Implementing Enhanced Barrier Precautions in Nursing Homes

Despite guidance from the CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommending Enhanced Barrier Precautions (EBP) to contain the spread of multidrug-resistant organisms (MDROs), its adoption in nursing homes has been inconsistent. New research highlights key findings, challenges, and recommendations for improving infection prevention practices.

Infection Control Today^® (ICT^®) invited Stephanie Mayoryk, MAS, BSN, RN, CIC, the infection preventionist and principal consultant at Mayoryk Consulting Services, and the study's lead author, back to ICT to discuss the study.

ICT: What was the primary motivation or research question that led you to conduct this study, and why do you believe it is important?

Stephanie Mayoryk, MAS, BSN, RN, CIC: This study aimed to assess the feasibility and acceptability of implementing EBP through a quality improvement (QI) initiative within 4 community-based nursing homes in Maryland. Our study objectives were to describe the elements of a quality improvement (QI) initiative for EBP implementation, assess the effectiveness of a QI initiative for EBP implementation, and assess the acceptability of EBP to health care personnel (HCP) and the barriers and facilitators of EBP for HCP.

Guidance from the CDC and HICPAC has recommended that EBP contain multidrug-resistant organism (MDRO) transmission. Yet, the full adoption of EBP by nursing homes has been variable, and EBP remains a new concept for HCP. Many facilities are beginning implementation in response to CMS requiring it in March 2024. Facilities need to have an evidence-based framework for implementation and evaluate administrative, environmental, HCP, and resident considerations before, during, and after EBP implementation.

ICT: Can you briefly explain the methodology you used in the study and why you chose this approach?

SM: We randomly staggered the implementation of the QI initiative to optimize EBP implementation in 4 mixed short—and long-stay units within 4 community-based nursing homes in Maryland. The facilities belong to the same independent health care system specializing in postacute care, skilled nursing, and rehabilitation. The study timeline included a 3-month baseline period, a training period, and a 3-month intervention period.

To operationalize EBP into practice, we utilized the 4E process model (engage, educate, execute, evaluate), a Translating Research into Practice (TRiP) model component. This model was chosen because it is well-suited for larger projects that include multiple sites and has been utilized in past health care epidemiology and infection control implementation initiatives.

We performed weekly observations of HCP providing care for residents with chronic wounds, devices, and MDROs. During these observations, data was collected on the types of care performed, hand hygiene, and gown and glove use during high-contact care. We also recorded whether EBP had been correctly implemented for eligible residents and whether PPE was available if required at the point of use.

To assess the adaptive aspects of implementation, mini-interviews were conducted with willing HCPs and infection preventionists (IPs) after the 3-month intervention period. All occupational groups that care for residents on EBP, including registered nurses, nursing assistants, licensed practical nurses, and respiratory therapists, were invited to participate.

ICT: What were the key findings of your study, and how do they contribute to the existing body of knowledge in your field?

SM: Overall, 1 in 3 nursing home residents met EBP indications. The most common indication (21% of 780 residents) was a history of MDRO colonization. Indwelling medical devices or chronic wounds were present in 14% and 10% of residents, respectively.

Accurate identification of residents meeting the EBP criterion improved significantly from 63% during the baseline period (with over 600 observations) to 99% during the intervention period. Among rooms with residents who met the EBP criterion, the percentage with gowns available at the point of use also increased significantly from 55% at baseline to 100% during the intervention period.

We also noted improved HCP compliance with glove and gown use during high-contact care activities. Glove use increased from 85% at baseline to 97%. Gown use increased from 27% to 78% during the intervention period. All high-contact care activities demonstrated increased glove and gown use from baseline to intervention period. The high-contact care activities with the highest level of glove compliance during the baseline period were wound and device care at 98% and 95%, respectively. The high-contact care activities with the lowest level of gown compliance during the intervention period included resident transfers and linen changes, at 66% and 80%, respectively.

Interviewed staff could identify both facilitators and barriers to EBP implementation. The 2 most frequently mentioned facilitators were the perception that EBP helps to reduce transmission of infectious diseases to other residents, staff, and families (74%) and that clear, simple, and bright signage helps to know when and where EBP can be used (69%). The 2 most frequently mentioned barriers to EBP implementation were that gowns are uncomfortable and hot (43%) and that there needs to be more clarity in knowing when a resident can be placed on EBP instead of contact precautions (34%).

These findings are significant as they demonstrate that HCP can achieve improved adherence with high-contact care activities and correctly identify residents eligible for EBP. However, the results also highlight where additional work is needed, such as improving gown and glove during resident transfers and linen changes and increasing HCP and IP knowledge of when a resident with an MDRO would require Contact Precautions instead of EBP.

ICT: Were there any unexpected research results or challenges you encountered?

SM: HCPs noted additional facilitators and barriers during post-implementation interviews. These included gown comfort and providing multiple gown options, the preference for more frequent informal education on the unit, EBP signage that was visually different from traditional transmission-based precautions signage, and the need for more frequent trash removal due to increased gown waste. Ensuring these elements are assessed and mitigated may improve future implementations.

ICT: What are your findings' potential implications or applications, and what future research directions do you suggest based on your study?

SM: Our findings support that the 4E implementation model can successfully be used for EBP implementations and other infection prevention and control interventions in nursing home settings. Though the recent adoption of EBP in CMS regulation may lead to hurried implementations, nursing homes may benefit from a stepwise approach to EBP implementation, including leadership training, environmental assessments, and gap analyses, and frequent HCP and resident/family education. Future EBP implementation efforts should focus on mitigating identified barriers.

Mayoryk S, O’Hara LM, Robinson GL, Lydecker AD, Jacobs Slifka K, Jones H, Roghmann MC. Optimizing the implementation of Enhanced Barrier Precautions in community-based nursing homes. Am J Infect Control. Published online September 20, 2024. doi:10.1016/j.ajic.2024.09.014

Study’s authors:

Stephanie Mayoryk, MAS, BSN, RN, CIC

Lyndsay M. O’Hara, PhD, MPH

Gwen L. Robinson, MPH

Alison D. Lydecker, MPH

Kara Jacobs Slifka, MD, MPH

Heather Jones, DNP, NP-C

Mary-Claire Roghmann, MD, MS