Updated CMS Recommendations for Infection Prevention in Long-Term Care

Robbie Hilliard, MSN, RN, CIC;

In an age of increasing antimicrobial resistance, evidence shows that the traditional use of contact precautions in nursing homes is not reasonable for most residents to prevent multidrug-resistant organism (MDRO) transmission. Contact precautions require room restrictions and are generally intended to be time-limited. Citing the inability to restrict residents to their rooms and negatively impacting their quality of life, the Healthcare Infection Control Practices Advisory Committee published a white paper, “Consideration for the Use of Enhanced Barrier Precautions in Skilled Nursing Facilities.”¹ Released in June 2021; the report noted that “more than 50% of nursing home residents may be colonized with an MDRO.”

The CDC then updated enhanced barrier precautions (EBP) recommendations in July 2022 with the report “Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs).”² Indwelling medical devices and wounds are major risk factors for colonization with an MDRO. Once colonized, these residents can serve as transmission sources throughout the facility. The expansion of EBP for all residents with wounds and indwelling medical devices is intended to protect these high-risk individuals from acquisition and from serving as a source of transmission if they are already colonized.

The CDC has been targeting MDROs in the health care setting since 2006, when it released the Management of Multidrug-Resistant Organisms in Healthcare Settings guidelines.³ Even so, MDROs continue to form and spread in health care settings across the US, so prevention efforts in transmission are still needed. Because these infections are often confirmed by labs long after patients are infectious, the basic prevention approach limits transmission.

Prevention efforts and activities are based on epidemiology, and this can vary by facility characteristics such as resident acuity, average length of stay, comorbidities, and facility design. The strategies included are designed to reduce transmission of MDROs at all stages of spread, from before a targeted MDRO is identified to after infection. These efforts are also designed to reduce the transmission of MDROs across a health care region, as facilities such as hospitals, dialysis clinics, and primary care offices often share the same patients. Communication of known MDROs with an interfacility transfer form or notification is critical in breaking the chain of transmission so all agencies can respond effectively during patient care.

According to the CDC, EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high-contact resident care activities.⁴ EBP was introduced in 2019 to prevent MDROs from spreading in long-term care environments. Until now, this guidance has not been included in the CMS/ State Survey Agency guidelines. However, the F880 Infection Prevention and Control regulations will include the EBP recommendations to align with national standards.

Considerations for Implementation

Posting universal and clear signage that communicates the type of required precautions on the door or wall outside the resident’s room is essential. The CDC offers universal signage that communicates effectively and is readily available on its website.
For EBP, signage should clearly indicate the high-contact resident care activities that require wearing a gown and gloves to prevent confusion.
Making PPE readily available immediately outside the resident rooms strongly encourages using it properly.
Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room). Adherence to hand hygiene is critical in stopping transmission.
Position a trash can inside the resident’s room and near the exit for discarding PPE after removal, before exiting the room, or before providing care to another resident in the same room.
Monitor and assess adherence to determine additional training and education needs.
Educate residents and visitors so that all stakeholders understand expectations.

EBP has been used historically in long-term care settings to aid in preventing the spread of MDROs in patients who have been colonized. For example, in the long-term care setting in Veterans Health Administration (VHA) facilities, every patient is screened for methicillin-resistant Staphylococcus aureus (MRSA) on admission. If a patient has a positive nasal swab result, they are placed on EBP, per the national VHA MDRO prevention initiative. This means when staff enter the room, they expect the room to be a high-germ area for MRSA, and they wear gowns to protect their clothing from transferring the germ if they have close physical contact with the patient.

Infection preventionists (IPs) in long-term care will have new compliance recommendations for EBP. CMS has incorporated the new guidance into the Infection Prevention and Control section listed in the appendix as F880. CMS often provides guidance via memos that further explain changes in regulations. Memo QSO-24-08-NH was released on March 21,

2024, updating the use of EBP in nursing homes.⁴ Effective April 1, 2024, long-term care surveyors will evaluate the use of EBP when performing resident tracers.

The bottom line is that if a patient in a long-term care facility has a wound or an indwelling device, they will be expected to be on EBP to prevent MDRO infection. Staff having direct/close physical contact should wear a gown to protect the resident from germs they may have picked up from other residents during care.

CMS is now adding EBP during high-contact activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status.^4,6,7 This is to prevent the spread of MDROs in the long-term care population. If the resident’s wound heals or the device is removed, they can return to standard precautions. Surveyors may interview staff to determine whether they know which residents require EBP before providing high-contact care activities and may cite facilities if personal protective equipment (PPE) is not readily available to staff.

Close physical contact refers to any time high-contact resident care is taking place. Examples include dressing, bathing/showering, transferring, providing hygiene, changing linens, and assisting with toileting or changing briefs. This also includes using or caring for devices such as central lines, urinary catheters, feeding tubes, tracheostomy tubes, or ventilators. The idea is to protect the resident’s opening from germs that could be transmitted from the health care worker.

Wounds are considered chronic and not shorter-lasting skin breaks, such as skin tears covered with a dressing. They refer to chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Indwelling medical devices include central lines (an intravascular catheter that terminates at or close to the heart or in one of the great vessels), urinary catheters, feeding tubes, and tracheostomy tubes. Peripheral IVs are not considered indwelling medical devices for EBP.

In a postpandemic world, PPE fatigue is rampant, and convincing staff to take an extra step before patient care may be challenging. Implementing routine EBP would incur additional costs for PPE (gowns/gloves), signage, staff training, and time to don and doff PPE. Staffing shortages and retention are already challenging the quality of care. Lack of executive leadership support can negatively impact efforts, as can a negative workplace culture.

On the contrary, potential savings would include avoiding infections and hospitalizations and creating a safer environment for residents. This intervention would be a good start to decreasing health care–associated infections (HAIs) for facilities with increased MDROs in their resident population. These measures could also prevent subsequent outbreaks of serious infections such as Candida auris by requiring screening and culturing and more rigid isolation and visitation procedures.

The CDC has provided tools and resources for implementing EBP, including educational materials and signage. There is a continuing education webinar recording with slides, a preimplementation planning tool, an observations tool with a summary spreadsheet, and template letters that can be modified to use for leadership. There is a video called “Enhanced Barrier Precautions in Nursing Homes.”⁷ There are print resources, such as an EBP step-by-step poster, staff pocket guides, and a poster called “Enhanced Barrier Precautions: How We Keep our Residents Safe.”⁸

One sure thing is that guidance will change as we learn how MDROs spread. During the COVID-19 pandemic, IPs held their breath while infection control standard practices like EBP gowning in MRSA-colonized rooms were not sustained to conserve PPE. The CDC now shows that significant increases in HAIs infections in 2021 compared with 2019 were the result.⁵ Despite the multiple reasons for this, it cannot be ignored that infection rates increased without using PPE. Preventing the transmission of MDROs will support resident safety and well-being, and any efforts supporting that should be encouraged.