Long-Term Care Infection Prevention

Exploring Enhanced Barrier Precautions

By Cindy Fronning

This column originally appeared in the October 2021 issue of Healthcare Hygiene magazine.

The title of this article raises some good questions. 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, these 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

Let’s examine the evolution of precautions to see how we got here.

Infection precautions of some sort have been used since the 14th century when ships were quarantined for 40 days out at sea to prevent the spread of the 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 20th century and the early years of the 21st 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.

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 the resident to be restricted to their rooms, thus providing the goal of reducing MDRO spread while maintaining residents’ quality of life.

Perhaps to put enhanced 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
• Changing briefs or assisting with toileting
• Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator
• Wound care: any skin opening requiring a dressing3

Other resident care does not require these precautions unless indicated by Standard Precautions. Residents are free to come and go from their rooms. See Table 2 for a breakdown of the three precautions.
Table 2: Summary of PPE Use and Room Restriction When Caring for Residents Colonized or Infected with Novel or Targeted MDROs in Nursing Homes4

So, now you might be asking, how do I implement this guidance? There are six steps to using these precautions and they also apply to Contact Precautions. The most important factor is to ensure that staff are aware of the facility’s expectations regarding these precautions.
1. Signage: Be sure you have proper signs posted on the resident’s door or wall next to the door regarding the precaution. It should indicate the PPE required and for Enhanced Barrier Precaution it should Indicate which high contact activities require the PPE.
2. PPE: Critical to have appropriate and adequate PPE supplies outside the room.
3. Alcohol-based handrub (ABHR): Access to ABHR both inside and outside the room is preferable.
4. Trash can: Location of a trash can just inside the resident’s room door to allow for PPE removal.
5. Monitoring and assessment: To ensure that staff are following the policies and procedures for these precautions and to determine if additional education is needed. This can be random, under cover and planned/scheduled.
6. Education: Provide residents and family members with education and training opportunities on these precautions and why they are necessary.

Prevention of MDRO transmission in nursing homes requires more than just proper use of PPE and room restriction. Education, training, and monitoring is also needed to ensure the implementation of other recommended infection prevention practices (such as hand hygiene, environmental cleaning, proper handling of wounds, treatment of indwelling medical devices, and disinfecting of resident-care equipment) are occurring appropriately.

Cindy Fronning, RN-BC, CDONA, FACDONA, RAC-CT, IP-BC, AS-BC, is the director of education at NADONA. She was a national consultant for more than 20 years and developed and teaches the infection prevention and control certificate of mastery and antibiotic stewardship certificate of mastery courses.


1. https://www.infectioncontroltoday.com/view/enhanced-barrier-precautions-new-approach-preventing-spread-multidrug-resistant-organisms-nursing

2. https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html
3. https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html
4. https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html
5. https://www.infectioncontroltoday.com/view/enhanced-barrier-precautions-new-approach-preventing-spread-multidrug-resistant-organisms-nursing



The Long-Term Care Perspective


Editor's note: This column originally appeared in the June 2021 issue of Healthcare Hygiene magazine.

Recently I had a facility ask what the Occupational Health and Safety Administration (OSHA) had to do with nursing homes. She had been asked for a bloodborne pathogen (BBP) plan and didn’t have one. She was of the opinion that she didn’t need one since her facility was a nursing home and not a hospital or industry-driven organization.

First, some history. OSHA was established under the Occupational Safety and Health Act of 1970. It was created to ensure safe and healthful working conditions for workers by setting and enforcing standards and by providing training, outreach, education and assistance.

The Occupational Exposure to Blood Borne Pathogens Standard, § 1910.1030(d)(3) (56 FR 64175) published in 1991, protects workers who can reasonably be anticipated to contact blood or other potentially infectious material (OPIM) as a result of performing their job duties. This applies to any employer with this potential -- hospitals, post-acute facilities, freestanding labs, etc.

The Centers for Disease Control and Prevention (CDC) estimates that 5.6 million workers in the healthcare industry and related occupations are at risk of occupational exposure to bloodborne pathogens, including human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and others. All occupational exposure to blood or other potentially infectious materials (OPIM) places workers at risk for infection from bloodborne pathogens.

Other potentially infectious materials include other body fluids such as semen, vaginal secretions, cerebrospinal fluid and saliva to name a few.

In the years following the BBP standard’s publication, the CDC found that nearly 600,000 percutaneous injuries were sustained by healthcare workers annually involving contaminated sharps. Due to the concern over these exposures and the technological developments which can improve employee protection, the Needlestick Safety and Prevention Act was passed in 2000 which directed OSHA to revise the BBP Standard, requiring employers to identify and make use of effective and safer medical devices. This revision was effective April of 2001.

So, what does this mean for long-term care facilities? The BBP standard must be followed. The BBP plan must have these components:

A written exposure plan to eliminate or minimize exposures that identifies which job classifications are at risk, together with a list of task/procedures that might result in an exposure.
The plan must be updated annually to reflect the following:
• Changes in tasks /procedures
• Positions
• Technological changes that might eliminate or reduce exposure
• Use of safer medical devices
• Document solicited input from frontline workers in identifying, evaluating and selecting effective engineering and work practice controls.
• Implementation of standard precautions.

Identify and use engineering controls such as sharps disposal containers, self-sheathing needles and sharps with engineered sharps injury protection and needleless systems.

Identify and ensure the use of work practice controls. These are practices that reduce the possibility of exposure by changing the way a task is performed.

Provide personal protective equipment (PPE), such as gloves, gowns, eye protection, and masks and the necessary fit testing if using N95 respirators.

Make available hepatitis B vaccinations to all workers with occupational exposure.

Make available post-exposure evaluation and follow-up to any occupationally exposed worker who experiences an exposure incident.

Use labels and signs to communicate hazards.

Provide information and training to workers

Maintain worker medical and training records including sharps injury log

Although the BBP standard is the main OSHA regulation that long term care facilities must follow, the premise of OSHA is one that we as employers must keep in mind at all times; to provide a safe and healthful working environment for our workers, and it carries a very high priority. Whether it is workplace violence, emergency preparedness or BBP we must be aware and always seeking ways to improve and provide the best working place we can for our employees.

COVID -19 placed a huge burden on the post-acute arena to not only keep our residents and clients safe and infection free but also our employees. Many of us lost employees to this pandemic infection. Those employees may have contracted the infection in the community or possibly at work. With that in mind we have reporting responsibilities not only to the Centers for Medicare & Medicaid Services (CMS), CDC, NSHN but also to OSHA.

OSHA was and is very much involved as evidenced by the three Interim Enforcement Response plan memorandums issued April 13, 2020, May 19, 2020 and March 3, 2021 involving annual fit testing of respiratory protection; six enforcement discretion memorandums dating from March 14, 2020 to Oct. 2, 2020 regarding respiratory protection; and three other memorandums addressing recording and reporting occupational injuries and illnesses and various standards that require annual or recurring audits, reviews, training or assessments.

OSHA has been surveying post-acute care facilities through the pandemic:
- 310 OSHA surveys have taken place in 23 states as of Jan. 14, 2021
- 912 tags have been issued resulting in more than $4 million in fines
- New York had 64 surveys with 172 tags and New Jersey had 101 surveys with 324 tags

The tags issued were similar among the 310 surveys (some facilities had multiple surveys done); they included PPE and reporting.
 1910.134(e) Medical evaluation: specifies the minimum requirements for medical evaluation that employers must implement to determine the employee's ability to use a respirator
 1910.134(e)(1) General: employer shall provide a medical evaluation to determine the employee's ability to use a respirator, before the employee is fit tested or required to use the respirator in the workplace.
 1910.134(f)(1) Fit Testing: Fit testing is required prior to initial use, whenever a different respirator facepiece is used, and at least annually thereafter.
 1910.134(g)(1)(i)(A) The employer shall not permit respirators with tight-fitting facepieces to be worn by employees who have facial hair that comes between the sealing surface of the facepiece and the face or that interferes with valve function;
 1904.29(a) Basic requirement. OSHA 300, 300-A, and 301 forms, or equivalent forms, for recordable injuries and illnesses must be used. The OSHA 300 form is called the Log of Work-Related Injuries and Illnesses, the 300-A is the Summary of Work-Related Injuries and Illnesses, and the OSHA 301 form is called the Injury and Illness Incident Report. (https://www.osha.gov/recordkeeping/forms)
 1904.39(a)(1) Within eight (8) hours after the death of any employee as a result of a work-related incident, you must report the fatality to the Occupational Safety and Health Administration (OSHA), U.S. Department of Labor.
 1904.39(a)(2) Within twenty-four (24) hours after the in-patient hospitalization of one or more employees or an employee's amputation or an employee's loss of an eye, as a result of a work-related incident, you must report the in-patient hospitalization, amputation, or loss of an eye to OSHA.
 1904.39(a)(3) You must report the fatality, inpatient hospitalization, amputation, or loss of an eye

In reviewing complaints to OSHA regarding essential industries (healthcare, retail trade, grocery stores, construction, general warehousing, restaurants/eating establishments and auto repair) healthcare had 45 percent of the complaints issued.

The take-away from all this data are some questions that we need to ask ourselves regarding our facility and OSHA responsibilities:
- Do we have a complete BBP plan that is reviewed annually?
- Are we providing the training on the BBP plan and do we make it available to our employees?
- Are providing the appropriate PPE and providing fit testing when employees use N95 respirators?
- Are we gathering input from our employees and using that data to edit and improve our plan?
- Are we documenting and retaining that documentation for the time period indicated?
- Are we using the OSHA forms 300, 300A, and 301 and posting 300A from Feb. 1 to April 30 each year?
- How satisfied are our employees with the efforts we are expending to keep them safe?

Are we ready for a visit from OSHA? Can we afford to be unprepared for the sake of our residents/clients and staff? If you haven’t given OSHA much attention in the past, it might be time to sit down and do a thorough review of the facility BBP plan, supplies/equipment and reporting process.

Cindy Fronning, RN, GERO-BC, IP-BC, AS-BC, RAC-CT, CDONA, FACDONA is a master trainer and director of education for the National Association of Directors of Nursing Administration in Long-Term Care (NADONA).

1. https://www.osha.gov/aboutosha
2. https://www.osha.gov/bloodborne-pathogens/hazards


Standard Precautions Versus Universal Precautions to Control BBPs