CMS Implements Enhanced Barrier Precautions Effective April 1, 2024

The Centers for Medicare and Medicaid Services (CMS) issued QSO-24-0​8-NH regarding the implementation of enhanced barrier precautions (EBPs) in nursing homes to prevent the spread of multi-drug resistant organisms (MDROs). While EBPs were introduced by the Centers for Disease Control and Prevention (CDC) in 2019, they were not included in guidance for State Survey Agencies (SSAs). This memo issues formal guidance under F880 Infection Prevention and Control to SSAs and long term care facilities on the use of EBP, aligning with the existing national standards effective April 1. 

EBPs are used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) during high-contact resident care activities both inside and outside the residents’ room, which can result in transferring MDROs to staff hands and clothing. EBPs should be followed when performing transfers or assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility.

EBPs are indicated for residents with any of the following, regardless of where they reside in the facility:

• Infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply.

• Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.

• • ​Wounds include chronic wounds, such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage or similar dressing, do not require EBP.

• • ​Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for EBP.

Facilities 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 the CDC.

CMS notes that facilities have some discretion when implementing EBP and balancing the need to maintain a homelike environment for residents. Residents are not restricted to their rooms or limited from participation in group activities. Because EBPs 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.

Effective implementation of EBP requires staff training on the proper use of PPE and the availability of PPE with hand hygiene products at the point of care.

Educational resources for EBP implementation include:

• The CDC provides several resources for providers when implementing EBP, including educational materials and signage.

• The CDC offers a short video regarding EBP in LTC centers on its YouTube channel.

• The CDC TRAIN environment provides additional resources.

• A CDC Frequen​tly Asked Questions site is also available.