Optimal Use of Enhanced Barrier Precautions in Nursing Homes to Prevent the Transmission of MDROs
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Enhanced barrier precautions (EBP) is a new type of transmission-based isolation precautions developed specifically for the nursing home environment. EBP refer to the use of gown and gloves during high-contact nursing home resident care activities. The CDC recommends EBP for residents with a history of multi-drug resistant organism (MDRO) colonization or with chronic wounds or devices regardless of MDRO colonization to interrupt the transmission of MDRO. The current CDC guidance for EBP places too many nursing home residents on EBP. We need to better risk stratify residents for EBP to minimize the burden on nursing homes and their staff while preventing patient to patient MDRO transmission. The large trials that could identify the highest risk populations are costly and now unlikely to be performed. Because of this, we should define the indications for EBP based on the risk of transmission estimated by the quantity of MDRO which contaminate HCP gown and gloves after routine care. Nursing homes have different levels of care with short stay residents, long stay residents and, in a small minority of nursing homes, residents who require chronic ventilatory support (aka chronic ventilator residents). Our preliminary data suggests that chronic ventilator residents are a high-risk population for MDRO transmission and should be targeted for EBP regardless of known MDRO colonization. As an example, 9 of 25 enrolled chronic ventilator residents show that HCP gloves and gowns can be contaminated with high quantities (>300 CFU per gown or glove swab) of carbapenem-resistant Acinetobacter baumannii. A critical limitation of our current study is that we have no control group of non-ventilated nursing home residents using similar methodology. To fill this gap, we propose to enroll an additional 50 short stay and long stay residents who are MDRO colonized to provide a comparison group to the MDRO colonized chronic ventilator unit residents. Our aims are: 1) to quantify the risk of MDRO transmission from resident care activities in 50 MDRO colonized short and long stay residents of multiple community-based nursing homes and 2) compare that to the current study of 50 MDRO colonized chronic ventilator residents. The results of this R21 will assess the feasibility of using the relative risk of MDRO transmission from quantitative cultures of gowns and gloves after resident care activities from MDRO colonized chronic ventilator residents, long stay residents and short stay residents. On a larger and more generalizable population, this approach could provide the CDC with the relative effectiveness of implementing EBP using different indications having a major impact on how our nursing homes use EBP. The expected outcome of this grant is to determine whether chronic ventilator residents are the highest priority population for which EBP should be applied in nursing homes.
