Enhanced Barrier Precautions (EBP): What It Requires That Standard and Contact Precautions Do Not

Enhanced Barrier Precautions (EBP) are a targeted gown-and-glove intervention for nursing homes: personal protective equipment worn during eight specific high-contact resident care activities, for residents who have a chronic wound or an indwelling medical device or a multidrug-resistant organism (MDRO) — without the room restriction, private-room placement or dedicated equipment that Contact Precautions require. EBP sits between Standard Precautions and Contact Precautions, and it is the middle position that facilities most often get wrong: the two failure modes seen on survey are treating EBP as if it were Contact Precautions (isolating residents who should not be isolated) and treating it as if it were Standard Precautions (waiting for anticipated blood or body-fluid exposure before donning).

This guide is written for the infection preventionist implementing EBP in a skilled nursing facility. It sets out the three-way distinction, the exact activity triggers, the CMS regulatory hook that makes EBP a surveyable expectation rather than a recommendation, and — the part no single source publishes — the five specific points where CDC’s guidance and CMS’s surveyor guidance do not say the same thing.

Sources and verification note (checked August 2026): cdc.gov blocks automated retrieval and returned HTTP 403 to every attempt made for this page, including with a browser user-agent. CDC’s two EBP documents were therefore read via the RestoredCDC.org archive, whose own disclaimer states its content was archived on 6 January 2025 — the page-level dates in that archive are 2 April 2024 for the implementation guidance (content marked “Updates as of July 12, 2022”) and 28 June 2024 for the FAQs. Anything CDC has published or revised since January 2025 is outside what could be checked here; confirm current text at cdc.gov before writing facility policy. The CMS memo was retrieved directly from cms.gov as a PDF and quoted from the primary document.

Standard, Enhanced Barrier, and Contact Precautions: the three-way distinction

All three are additive layers, not alternatives. Standard Precautions apply to every resident at all times and continue to apply while a resident is on EBP or Contact Precautions. The distinction is what triggers the gown and gloves, and what else the precaution imposes on the resident.

	Standard Precautions	Enhanced Barrier Precautions	Contact Precautions
Applies to	Every resident, always	Residents with a chronic wound and/or indwelling device (regardless of MDRO status), or infection/colonization with a CDC-targeted MDRO when Contact Precautions do not apply	Residents with uncontainable secretions or excretions, an outbreak-investigation directive, or another Appendix A condition (C. difficile, norovirus, scabies)
Gown and gloves triggered by	Anticipated exposure to blood, body fluids, mucous membranes, non-intact skin or contaminated surfaces	Performing one of eight named high-contact resident care activities — even with no anticipated blood or body-fluid exposure	Any room entry, regardless of the care being provided
When PPE is donned	Before the anticipated exposure	Before the high-contact activity — not necessarily before room entry	Before room entry; doffed before room exit
Private room	No	No — shared rooms permitted	Yes (or cohorting by pathogen)
Dedicated resident-care equipment	No	No	Yes (e.g. dedicated stethoscope, blood-pressure cuff)
Room restriction / group activities	None	None — residents may leave the room and join group activities	Restricted to room except for medically necessary care; excluded from group activities
Intended duration	Permanent	Duration of stay, or until the wound resolves or the device is discontinued	Time-limited, with a de-escalation plan

The single most consequential row is when PPE is donned. Under Contact Precautions, gown and gloves go on at the doorway. Under EBP they go on before the high-contact activity — so staff entering to answer a call light, converse with a resident or pass medications without performing a high-contact activity would generally not don PPE at all. CMS states this explicitly in QSO-24-08-NH and permits PPE supplies to be positioned near or outside the room rather than at every doorway. If your facility is stationing an isolation cart outside every EBP room and gowning at the threshold, you have implemented Contact Precautions under an EBP sign.

For the full three-category framework EBP sits alongside, see our guide to Contact, Droplet and Airborne transmission-based precautions; for the engineering side of airborne isolation, see airborne infection isolation room specifications.

What puts a resident on EBP

Two independent branches, either of which is sufficient (assuming Contact Precautions do not otherwise apply):

1. A chronic wound and/or an indwelling medical device — regardless of MDRO colonization status, and regardless of whether any MDRO has ever been identified in the facility. CDC’s rationale is that wounds and devices are themselves acquisition risk factors, and that most colonized residents are asymptomatic and unidentified.
2. Infection or colonization with an MDRO — at minimum a CDC-targeted or novel organism; optionally, a locally epidemiologically important one.

CDC-targeted MDROs, as listed in the implementation guidance: pan-resistant organisms; carbapenemase-producing carbapenem-resistant Enterobacterales; carbapenemase-producing carbapenem-resistant Pseudomonas spp.; carbapenemase-producing carbapenem-resistant Acinetobacter baumannii; and Candida auris.

Additional epidemiologically important MDROs a facility or health department may add: MRSA, ESBL-producing Enterobacterales, VRE, multidrug-resistant Pseudomonas aeruginosa, and drug-resistant Streptococcus pneumoniae. Which organisms are epidemiologically important locally is a judgment informed by local epidemiology, outbreak history, transmissibility in healthcare settings, severity of outcomes and current prevention priorities — your regional antibiogram is the natural evidence base for that call, and our guide to building and reading a cumulative antibiogram covers how to construct one.

EBP is not a substitute for Contact Precautions where those are separately indicated. C. difficile, norovirus and scabies remain Contact Precautions conditions per Appendix A of the CDC Guideline for Isolation Precautions. And CDC does not recommend screening residents for MDRO carriage for the sole purpose of deciding EBP status — EBP is designed to key off resident risk factors and care activity, not off a test result.

The eight high-contact resident care activities

Gown and gloves are worn for these, and generally not for other care unless Standard Precautions independently require them:

• 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 dressing

Gown and gloves are the minimum. Where the activity carries a splash or spray risk — wound irrigation, tracheostomy care — Standard Precautions adds face protection on top.

The definitional traps in that list

“Wound” means two different things depending on which question you are answering. For eligibility — deciding whether a resident goes on EBP at all — the intent is chronic wounds: pressure ulcers, diabetic foot ulcers, venous stasis ulcers, and (in CMS’s phrasing) unhealed surgical wounds. A skin tear under an adhesive bandage does not put a resident on EBP. But for the activity trigger, wound care is defined as care of any skin opening requiring a dressing. A resident already on EBP for an indwelling catheter gets gown and gloves for a minor dressing change; a resident whose only skin issue is that minor dressing does not go on EBP because of it. Conflating those two definitions is the most common over- and under-application error.

“Indwelling medical device” excludes more than most policies assume. A device qualifies if it provides a direct external pathway into the body: central vascular catheters including hemodialysis catheters and PICCs, indwelling urinary catheters, feeding tubes, tracheostomy tubes. Fully embedded devices with no external component — a pacemaker — do not qualify. CDC’s FAQ additionally states that peripheral IVs (with the explicit exception of midline catheters), continuous glucose monitors and insulin pumps are not currently indications, and that an ostomy without an associated indwelling device is neither a device nor a wound for EBP purposes.

“Providing hygiene” means brushing teeth, combing hair, shaving. CDC’s stated expectation is that these activities are usually bundled into morning and evening care; isolated hair-combing not bundled with other high-contact care would not generally require gown and gloves.

“Device care or use” — the safest practice is gown and gloves for any care or use of the device. CDC allows gloves alone for limited-contact uses (passing medications through a feeding tube, for example), but only where the activity is not bundled with other high-contact care and there is no evidence of ongoing transmission. If you rely on that allowance, define the limited-contact activities explicitly in policy and train to them; an undocumented local carve-out is what a surveyor will find.

Where EBP applies outside the resident room

EBP is primarily aimed at care inside the resident’s room, where high-contact activities cluster together and contact is prolonged. Transfers in dining or activity rooms — short-duration contact — generally do not require gown and gloves. EBP does follow the resident into a shared or common shower room, and into the therapy gym: physical and occupational therapists should gown and glove when they anticipate prolonged close body contact during transfers and mobility work. Environmental services staff changing the linens of an EBP resident are performing a high-contact activity and should gown and glove; EVS gowning for other housekeeping tasks in an EBP room is a facility-policy decision, whereas EVS gowning for a Contact Precautions room is expected.

The five places CDC and CMS do not say the same thing

This is the cross-walk that matters on survey, because your surveyor is working from the CMS memo and your clinical policy is probably written from the CDC page. The two are aligned in substance and diverge in five specific, checkable ways.

Point	CDC guidance / FAQs	CMS QSO-24-08-NH (F880)
Non-CDC-targeted MDROs	Facilities and jurisdictions have flexibility to include locally important MDROs (MRSA, VRE, ESBL, etc.)	Explicitly “at the discretion of the facility” in Table 1 — and surveyors are directed to focus their evaluation of EBP use as it relates to CDC-targeted MDROs
Midline catheters	Named as an exception: peripheral IVs are not an indication except midline catheters	Silent on midlines; states only that a peripheral IV that is not a PICC is not an indwelling device
Unhealed surgical wounds	Chronic-wound examples given are pressure ulcers, diabetic foot ulcers, chronic venous stasis ulcers	Adds unhealed surgical wounds to the chronic-wound examples
Signage	Post clear signage outside the room stating the precaution type and required PPE; for EBP the sign should also list the high-contact activities. Generic “see the nurse” signs are explicitly inadequate	Facilities have discretion on how to communicate; CMS “supports facilities in using creative (e.g., subtle) ways” to preserve a home-like environment, provided staff know before providing care
PPE placement	Make gowns and gloves available immediately outside the resident room	Discretion in placement — “near or outside the resident’s room” — and PPE “may not need to be donned prior to entering the resident’s room”

Two practical consequences. First, the signage divergence is real and it is where facilities most often feel caught between resident dignity and audit evidence: CMS’s discretion language is the more permissive of the two, but discretion in method is not discretion in outcome — staff must demonstrably know which residents require EBP before they begin high-contact care, and whatever mechanism you choose has to survive a surveyor asking a CNA that question directly. Second, note that whichever mechanism you use, CDC is unambiguous that the sign must not disclose the resident’s diagnosis or the reason for the precaution; doing so is a HIPAA and dignity problem, and the precaution-type-plus-PPE format exists precisely to avoid it.

The regulatory hook: F880, 42 CFR 483.80, and the April 2024 date

EBP became a surveyable expectation for Medicare- and Medicaid-certified long-term care facilities through CMS memorandum QSO-24-08-NH, “Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs),” dated 20 March 2024, with a stated Effective Date: April 1, 2024. The memo folds the EBP guidance into F880 Infection Prevention and Control, which implements 42 CFR 483.80 — the requirement that a facility establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections.

That is the whole compliance mechanism, and it is worth being precise about what it does and does not create. It does not create a new regulation; 483.80 was already there. It changes the interpretive guidance surveyors apply to that regulation, which is why an EBP failure is cited as an F880 deficiency rather than under a new tag. Facilities are given explicit discretion in balancing EBP against maintaining a home-like environment, and surveyors evaluate EBP when reviewing sampled residents for whom EBP is indicated.

The scope boundary matters as much as the date: this applies to nursing homes. CDC’s FAQ states plainly that EBP is not recommended for other healthcare settings — acute care hospitals and long-term acute care hospitals continue to use Contact Precautions as their MDRO strategy, and the implementation guidance says on its face that it is not intended for those settings. The evidence base behind EBP was also built on observations in adult nursing home populations; facilities with pediatric residents that adopt EBP may need to redefine what counts as a high-contact activity for developmental reasons.

Background worth knowing when you are asked why this changed: CDC introduced EBP in 2019 as a narrower, response-oriented tool. The June 2021 HICPAC white paper “Consideration for the Use of Enhanced Barrier Precautions in Skilled Nursing Facilities” documented that more than 50% of nursing home residents may be colonized with an MDRO and that room-restriction-based Contact Precautions were, in practice, not being applied broadly enough to interrupt that. CDC’s July 2022 update expanded EBP to all residents with wounds or devices regardless of MDRO status and to facility-wide rather than outbreak-response use; CMS’s 2024 memo aligned federal surveyor guidance to that expansion.

Current status, dated: CDC’s implementation page carries a standing “For Awareness” notice that the EBP recommendations are being reviewed as part of updates to the 2007 Guideline for Isolation Precautions, and that a HICPAC-finalized draft will be posted in the Federal Register for public comment before returning to HICPAC. As of the archive read for this page, that revision had not been finalized. Treat the July 2022 guidance as current and check the Federal Register and HICPAC meeting materials before assuming otherwise.

Duration and discontinuation

EBP is intended to last the duration of the resident’s stay. The one clean off-ramp is risk-factor resolution: a resident placed on EBP solely because of a wound or device can return to Standard Precautions alone when the wound heals or the device is removed.

A resident colonized with a novel or CDC-targeted MDRO stays on EBP for the duration of stay. CDC does not recommend routine retesting to clear a resident, and does not accept a subsequent negative test as grounds for discontinuation — colonization is typically prolonged and clearance testing yields false negatives. This is the mirror image of the discontinuation ambiguity in the 2007 guideline, which leaves MDRO Contact Precautions duration explicitly undefined; EBP resolves it by defaulting to “for the stay.”

Note also that EBP and Contact Precautions coexist within a facility. If one resident meets Contact Precautions criteria — uncontained secretions, acute diarrhea, draining wounds, or an active outbreak investigation — that does not suspend EBP for other at-risk residents. And a resident arriving from an acute care hospital on Contact Precautions for MDRO colonization can typically be managed on EBP in the nursing home instead, unless they have uncontainable secretions or excretions, are within an outbreak investigation window, or public health directs otherwise.

Implementation checklist

CDC’s implementation steps, restated as things a surveyor or an internal audit can actually observe:

• Signage or an equivalent mechanism that tells staff the precaution type and required PPE before care begins — and, for EBP, which activities trigger it. No resident diagnosis or reason on the sign.
• Gowns and gloves accessible at the point of use; CMS permits placement near or outside the room rather than a cart at every door.
• Alcohol-based hand rub in every resident room, ideally inside and outside.
• A trash receptacle inside the room near the exit so PPE can be doffed before leaving or before turning to a roommate.
• Shared-room controls where EBP residents have roommates: at least three feet between beds, privacy curtains, cleaning and disinfection of shared reusable equipment, a more frequent environmental cleaning schedule, and a PPE change plus hand hygiene when switching between roommates.
• Initial and refresher training, plus periodic observation of adherence — CDC publishes a pre-implementation tool and an observations tool for exactly this, and adherence monitoring is the piece most often missing.
• Resident and visitor education, including a letter to residents, families and volunteers explaining why gowns and gloves appear during some care and not others.

Adherence monitoring is also where EBP work naturally joins the rest of the quality programme: observation data, a measurable adherence rate and a corrective plan are precisely the structure a QAPI performance improvement project is built on, and EBP audit results are among the more defensible PIP topics available to a nursing home. Ownership of the programme sits with the infection preventionist, and MDRO prevention is inseparable from the facility’s antimicrobial stewardship programme — reducing selective pressure and reducing transmission are the two halves of the same problem. Device-associated infection surveillance for residents with the exact devices that trigger EBP is covered in our guides to CLABSI and CAUTI.

One waste-handling question comes up constantly and has a clear answer: applying the OSHA Bloodborne Pathogens Standard definition of “regulated waste,” most PPE used during EBP or transmission-based precautions care does not meet it and can be discarded as routine non-infectious waste — but state and local rules may be more restrictive than the federal standard, so check yours before writing the policy.

Frequently asked questions

What is the difference between Enhanced Barrier Precautions and Contact Precautions?

Contact Precautions require gown and gloves on every room entry, a private room (or cohorting), dedicated resident-care equipment, and restriction of the resident to their room including exclusion from group activities. Enhanced Barrier Precautions require gown and gloves only during eight named high-contact care activities, impose no room restriction, no private-room requirement and no dedicated equipment, and allow group participation. That is why Contact Precautions are time-limited with a de-escalation plan while EBP is intended to run for the resident’s stay.

What does EBP require that Standard Precautions do not?

Under Standard Precautions, PPE is selected on anticipated exposure to blood or body fluids. EBP requires gown and gloves for the eight high-contact activities even when no blood or body-fluid exposure is anticipated, because those activities were shown by direct observation to transfer MDROs to staff hands and clothing regardless. Standard Precautions continue to apply on top of EBP — if the activity carries splash risk, face protection is added.

Do residents on Enhanced Barrier Precautions need a private room?

No. Residents on EBP may share rooms. Single rooms should be prioritised for residents with an acute communicable infection or those on Contact Precautions for uncontainable secretions or excretions. Facilities with spare single-room capacity may still choose to use it, and cohorting residents with a novel or targeted MDRO in one wing is worth considering to limit staff movement between colonized and non-colonized residents.

Which MDROs trigger Enhanced Barrier Precautions?

At minimum, novel MDROs and those targeted by CDC: pan-resistant organisms, carbapenemase-producing carbapenem-resistant Enterobacterales, carbapenemase-producing carbapenem-resistant Pseudomonas spp., carbapenemase-producing carbapenem-resistant Acinetobacter baumannii, and Candida auris. Facilities may add locally epidemiologically important organisms such as MRSA, VRE or ESBL-producing Enterobacterales; CMS treats those additions as facility discretion and directs surveyors to focus on the CDC-targeted list.

Does a resident with only a peripheral IV go on EBP?

No. A peripheral IV that is not a PICC is not an indwelling medical device for EBP purposes. CDC’s FAQ carves out midline catheters as an exception — those are treated as an indication — and states that continuous glucose monitors and insulin pumps are not currently indications. The CMS memo does not address midlines, so document your position on them in policy.

When did EBP become a CMS requirement for nursing homes?

CMS issued QSO-24-08-NH on 20 March 2024 with an effective date of 1 April 2024, incorporating the EBP guidance into F880 Infection Prevention and Control under 42 CFR 483.80. It is interpretive surveyor guidance applied to an existing regulation, not a new regulation.

Do Enhanced Barrier Precautions apply in hospitals?

No. CDC has not recommended EBP outside nursing homes; acute care and long-term acute care hospitals continue to use Contact Precautions for MDRO transmission prevention. The rationale is specific to the nursing home setting, where indefinite room restriction conflicts with residents’ quality of life and, as a result, was simply not being applied.

Can we stop EBP if the resident tests negative for the MDRO?

No. CDC does not recommend routine retesting for clearance and does not accept a negative follow-up test as a basis for discontinuing EBP, because colonization is typically prolonged and clearance testing produces false negatives. The exception is a resident placed on EBP solely for a wound or device: when the wound heals or the device is removed, Standard Precautions alone may be appropriate.

Primary sources

• CMS, QSO-24-08-NH: Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), 20 March 2024, effective 1 April 2024 — retrieved directly from cms.gov and quoted from the primary PDF.
• CDC/NCEZID, “Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs)” — canonical location cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html; read for this page via the RestoredCDC.org archive because cdc.gov returned HTTP 403 to automated retrieval.
• CDC/NCEZID, “Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes” — same access caveat.
• HICPAC, “Consideration for the Use of Enhanced Barrier Precautions in Skilled Nursing Facilities,” June 2021 — cited by both CMS and CDC as the evidence summary behind EBP.
• CDC/HICPAC, Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007), Appendix A — the source for which conditions require Contact Precautions instead of EBP.
• 42 CFR 483.80; CMS State Operations Manual Appendix PP, F880.

This guide is part of CASRAI’s patient safety and infection prevention cluster.