By: Verona Bair, RN, DNS-CT, QCP, Certified Nursing Home Infection Preventionist, Manager of Safety and Risk Management, Functional Pathways
The Centers for Medicare & Medicaid Services incorporates Enhanced Barrier Precautions into its F880 infection prevention and control guidance for nursing homes. During the survey process, surveyors may evaluate whether a facility has appropriately identified residents who require Enhanced Barrier Precautions and whether staff consistently follow the required infection prevention practices.
Surveyors may pay particular attention to residents who are infected or colonized with multidrug-resistant organisms, or MDROs, targeted by the Centers for Disease Control and Prevention. They may also evaluate precautions for residents with wounds or indwelling medical devices, regardless of their known MDRO status.
Examples of MDROs currently targeted by the CDC include:
Methicillin-resistant Staphylococcus aureus, or MRSA, is not currently included on the CDC’s targeted MDRO list. However, MRSA and other organisms may be considered epidemiologically important based on local transmission patterns, public health recommendations and facility policies.
In long-term care settings, infection prevention is a fundamental component of delivering high-quality care. Residents are often more susceptible to infection and related complications because of age, underlying health conditions, wounds, medical devices and frequent contact with healthcare personnel.
Enhanced Barrier Precautions, or EBP, are an infection control intervention designed to reduce the transmission of MDROs in nursing homes. EBP builds upon Standard Precautions by requiring the targeted use of gowns and gloves during high-contact resident care activities.
Standard Precautions continue to apply to every resident, regardless of infection or colonization status. Additional personal protective equipment, such as face protection, may also be necessary when splashes or sprays are anticipated.
EBP is generally appropriate for residents who:
Colonization occurs when bacteria or fungi are present on or in a resident without causing symptoms of illness. Although the resident may not appear sick, the organism can still be transmitted to other people.
MDROs can persist on environmental surfaces and may be transmitted through contact with contaminated hands, clothing, equipment or resident surroundings. High-contact care activities create opportunities for organisms to move from a resident or the resident’s environment to healthcare personnel.
Gowns and gloves create a protective barrier during these interactions. When used correctly and combined with proper hand hygiene, environmental cleaning and equipment disinfection, they help reduce contamination and interrupt pathways of transmission.
EBP is not limited to residents already known to carry an MDRO. Many nursing home residents have wounds or indwelling medical devices that increase their risk of acquiring, carrying and transmitting these organisms.
Consistently applying EBP based on resident risk factors is therefore essential, even when an MDRO has not been identified.
Healthcare personnel should use gowns and gloves when performing designated high-contact care activities for residents who meet EBP criteria.
These activities may include:
Examples of indwelling medical devices may include:
These activities often require close or prolonged physical contact and may involve exposure to bodily fluids, contaminated surfaces or resident care equipment.
Residents requiring wound care may also be at increased risk. For EBP purposes, wound care generally involves caring for a skin opening that requires a dressing, particularly when the resident has a chronic or difficult-to-heal wound.
Examples include:
EBP does not replace Contact Precautions. Contact Precautions may be required when a resident has acute diarrhea, uncontrolled secretions, uncontained wound drainage or another condition that creates a greater risk of environmental contamination. Facilities should follow current CDC guidance, public health recommendations and their own infection prevention policies when determining the appropriate level of precautions.
Healthcare personnel may encounter MDROs throughout the workday. Without consistent adherence to hand hygiene, PPE, environmental cleaning and facility-specific clothing policies, contaminants may be transferred to hands, clothing, equipment and other surfaces.
Consider seeing someone wearing scrubs while shopping in a grocery store after a shift. Most people recognize that individual as a healthcare professional who has spent the day caring for others. The situation can also serve as a reminder of why infection prevention practices must be followed consistently before, during and after resident care.
Healthcare personnel should follow facility policies regarding PPE removal, hand hygiene, work clothing and the handling of potentially contaminated garments. These practices protect residents and staff within the facility while also helping reduce the potential for organisms to be carried into the broader community.
Effective staff education requires more than reviewing a policy or showing a presentation. Facilities should combine clear instruction, hands-on practice, competency validation and ongoing reinforcement.
Role-playing and simulation exercises can help staff understand how easily contamination may occur during routine care.
For example, a facility could conduct a simulation involving care for a resident with a percutaneous endoscopic gastrostomy, or PEG, tube. During the exercise, staff members would put on gowns and gloves and perform a care task using a mannequin.
A harmless substance, such as baking soda or another approved simulation material, could be placed around the PEG tube site, on the mannequin’s hands or on nearby surfaces to represent contamination. As staff complete the activity, they can observe how easily the material transfers to their gloves, gowns, hands or surrounding equipment.
This visual demonstration reinforces why PPE, appropriate removal techniques and hand hygiene are essential during routine care. It can also help staff identify potential gaps that may not be obvious during classroom-based instruction.
Interactive training strengthens understanding, improves confidence and supports a culture of safety and accountability.
Ongoing staff training and competency evaluations should confirm that employees can:
Training should include everyone whose work may bring them into contact with residents, resident rooms, equipment, laundry or potentially contaminated materials.
This may include:
Each department should understand how EBP applies to its specific responsibilities. For example, therapy employees should know when gowns and gloves are appropriate during close-contact mobility or transfer activities. Housekeeping personnel should understand how to clean rooms and equipment safely. Laundry staff should know how to handle potentially contaminated garments and reusable gowns.
Facilities can support consistent adherence by making the correct action clear, convenient and expected.
Place appropriate signage outside the resident’s room indicating which precautions are required. Signage should be easy to understand while protecting the resident’s privacy.
Keep gowns, gloves and alcohol-based hand sanitizer readily available near the location where care will be provided. Staff are more likely to follow protocols when supplies are easy to access.
Establish a regular inspection and restocking schedule. Maintain backup supplies to reduce the risk of shortages.
Use simulations, observations and drills to evaluate staff knowledge and reinforce correct techniques. Include realistic scenarios involving resident care, environmental cleaning, laundry and waste disposal.
Review whether EBP indications are accurately reflected in resident assessments, care plans and clinical documentation. Observe staff during care to determine whether facility policies are being followed.
Give employees timely, specific feedback following observations and competency evaluations. Reinforce correct practices and provide additional education when gaps are identified.
Failure to follow EBP protocols can place residents and staff at risk. Address noncompliance immediately through coaching, retraining and corrective action when appropriate.
EBP should be presented as a core infection prevention practice rather than an optional task. Leaders should consistently model expectations, recognize employees who follow procedures and encourage staff to speak up when they identify safety concerns.
Effective infection prevention requires more than having a written policy. Facilities must consistently implement their procedures, provide the necessary equipment, educate staff and evaluate whether their programs are working as intended.
Regular audits, competency evaluations, refresher training and leadership reinforcement help transform EBP from a regulatory requirement into a reliable part of everyday care.
By proactively using appropriate PPE, practicing hand hygiene and following evidence-based infection prevention procedures, healthcare professionals can reduce MDRO transmission and strengthen the safety and quality of care throughout the facility.
Invisible germs may be difficult to detect, but the actions used to stop their spread should always be visible, consistent and part of every resident interaction.
Centers for Disease Control and Prevention.
Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent the Spread of Multidrug-Resistant Organisms
Centers for Disease Control and Prevention.
Frequently Asked Questions About Enhanced Barrier Precautions in Nursing Homes
Centers for Medicare & Medicaid Services.
State Operations Manual, Appendix PP: Guidance to Surveyors for Long-Term Care Facilities
Centers for Medicare & Medicaid Services.
QSO-24-08-NH: Enhanced Barrier Precautions in Nursing Homes to Prevent the Spread of Multidrug-Resistant Organisms
Note: This memorandum expired on April 28, 2025. The EBP guidance was incorporated into the F880 guidance in Appendix PP. (Centers for Medicare & Medicaid Services)
Centers for Disease Control and Prevention.
Considerations for the Use of Enhanced Barrier Precautions in Skilled Nursing Facilities