As WHCA/WiCAL has previously reported, the Centers for Disease Control and Prevention (CDC) recently released updated guidance on the use of Enhanced Barrier Precautions (EBP) in nursing homes. This week, Wisconsin’s Department of Health Services (DHS), Healthcare-Associated Infections Prevention Program (HAI), issued the below communication. In addition to reviewing the updated CDC guidance, this state communication also addresses two other important points:

• DHS/HAI, while acknowledging that the enhanced guidance offers additional protection for residents and staff, also acknowledges that implementation will require additional staff time and effort, and will increase a nursing facility’s PPE costs.  DHS/HAI then offers guidance and suggestions on implementing the EBP;
• Importantly, HAI will be holding a webinar on the topic on Thursday, August 25^th at 10:30, the details of which for set forth below. 

The communication below states, “These recommendations, while not currently reviewed by regulatory bodies, are seen as current best practice and facilities should begin working toward their implementation.” Further, WHCA/WiCAL directly asked DQA leadership what this communication means for survey protocol in Wisconsin, and DQA indicated that as of now, survey/enforcement will not change as a result of this new CDC guidance. However, WHCA/WiCAL is following up with DQA to see what providers should expect now and in the near-term and long-term future related to this new guidance. We are also looking to clear up discrepancies with the CDC guidance and how DQA characterizes the guidance in the below communication.

WHCA/WiCAL has also asked DHS to consider funding sources that may be available to help offset increased operational costs associated with the need for additional PPE in order to be in alignment with the CDC guidance.

HAI Memo: New Enhanced Barrier Precautions Guidance for Nursing Homes

The Centers for Disease Control and Prevention (CDC) recently released updated guidance for the use of enhanced barrier precautions (EBPs) in nursing homes. EBPs are designed to reduce the spread of multidrug-resistant organisms (MDROs) by expanding the use of gloves and gowns during high-contact resident care activities, especially for those who are at an increased risk of acquiring or spreading an MDRO.

These changes were prompted by the increasing recognition that MDROs are prevalent in the nursing home setting. CDC notes two large-scale regional prevalence studies that found more than 50% of nursing home residents were colonized with an MDRO. Residents colonized with an MDRO may not show signs of illness and their colonization status may not be included in their medical history, but these residents can still spread that MDRO to others.

Guidance Updates 

Health care personnel may indirectly transfer MDROs from resident to resident during high-contact resident care activities via their hands and clothing. Studies have indicated that the use of EBPs can significantly reduce this spread.

The updated guidance now recommends EBPs for nursing home residents with any of the following:

• Infection or colonization with a targeted MDRO when contact precautions do not otherwise apply
• Infection or colonization with other epidemiologically important MDROs, when contact precautions do not otherwise apply
• Indwelling medical devices (for example, central line, urinary catheter, feeding tube, tracheostomy/ventilator) and/or chronic wounds, regardless of MDRO colonization status

CDC notes key differences from the original EBP guidance released in 2019, in that the new guidance:

• Expands the residents for whom EBP applies to include any resident with an indwelling medical device or chronic wound.
• Expands the types of MDROs for which EBP can be applied.

Implementation Considerations

The updated EBP guidelines will provide additional protections for both nursing home residents and staff to help control the spread of MDROs. At the same time, the Healthcare-Associated Infections (HAI) Prevention Program recognizes that implementation of the updated EBP guidance will require additional staff time and effort, as well as supply costs. Key considerations regarding the expanded guidelines:

• These recommendations, while not currently reviewed by regulatory bodies, are seen as current best practice and facilities should begin working toward their implementation.
• At a minimum, facilities should work to implement EBPs for those infected or colonized with a targeted MDRO (when contact precautions do not otherwise apply) and for those with chronic wounds and/or indwelling medical devices regardless of MDRO colonization status who reside on a unit or wing where a resident with a targeted MDRO resides. This is the EBP guidance that has been in place since July 2019.
• A key step in working toward full implementation of the expanded guidelines will be the assessment of the facility’s PPE supply and management practices. During this transition phase, it may be necessary at times, such as during an outbreak of COVID-19 or influenza, to temporarily modify EBP practices because of limited PPE supplies. In these situations, facilities should ensure that at minimum, they are implementing EBPs based on the original EBP guidance from 2019 (see above bullet point).
• Determining what additional epidemiologically important MDROs for which to use EBPs is at the discretion of each individual nursing home based on local risk assessment. This should include a discussion among facility leadership that considers past and current MDRO activity within the building, including MDRO prevalence, transmission, and outbreaks, as well as MDRO prevalence within the geographic region and among healthcare transfer networks.
• The reuse of PPE is discouraged. Per the white paper by the federal advisory group on which the updated EBP guidance is based, “When PPE supply chains are strained during extraordinary circumstances such as the COVID-19 pandemic, facilities may encounter shortages of gowns or gloves. Neither extended use nor reuse of gowns and gloves is recommended for mitigating shortages in the context of EBP.”
• As with the original EBP guidelines, residents on EBPs solely because of a chronic wound or indwelling device would remain on EBPs until the chronic wound is resolved, or the indwelling medical device is discontinued. Residents who are infected or colonized with an MDRO would remain on EBPs for the duration of their stay in the facility. This is because individuals may remain colonized with an MDRO for long periods of time, with intermittent shedding. For the same reasons, repeat testing of individuals colonized with MDROs is not recommended.

CDC’s expanded EBP guidance represents a proactive approach to preventing MDRO transmission in this population, as it does not wait until a particular MDRO is already in-house to act. While there may be challenges to expanding the use of EBPs beyond targeted MDROs, working toward implementation in stages may prove more feasible.

HAI Prevention Program Long-Term Care Education Series

Specific strategies for assessing your facility’s situation and planning for the implementation of the expanded EBP guidance will be discussed on the August 25 HAI Prevention Program Long-Term Care Education Series webinar.

Date: Thursday, August 25, 10:30 a.m.–12:00 p.m.

Access via Zoom or dial 1 669 254 5252

Webinar ID: 161 543 4498

Passcode: 712690

Additional Resources 

Visit CDC’s Frequently Asked Questions about Enhanced Barrier Precautions in Nursing Homes webpage for more information on the application and implementation of the new EBP guidance.

Additional information regarding the background and implementation of EBPs is available on the CDC website.

Other CDC resources include:

• Overview presentation.
• Sample letter for staff.
• Sample letter for residents, families, and visitors.

Questions

Consult with your Regional Infection Preventionist for additional questions related to EBPs or a staged implementation.

Contact your DQA Regional Field Operations Director (RFOD) for questions related to the regulatory or survey process, keeping in mind that EBPs have not yet been added to the CMS survey process at this time. As that process changes, additional communications will be distributed by DQA.