Enhanced barrier precautions at nursing home pickups: when transport crews gown and glove

A transport crew gowns and gloves only for high-contact care inside the resident’s room, and the gown comes off before the resident is in the van. The sign on the door says enhanced barrier precautions, a nursing home practice that CMS built into its infection control survey guidance on April 1, 2024. A crew that arrives for a wheelchair resident and meets that sign usually has one decision to make, which is whether anyone on the crew will touch the resident in a way the sign counts. The rest of the pickup routine is in nursing home pickups and returns, and cleaning after the trip is in the infection control guide.

What a barrier precautions sign tells a crew

The sign tells the crew which resident needs gown and glove protection for hands-on care, and it names the equipment, not the illness. CMS defines enhanced barrier precautions as targeted gown and glove use during high-contact resident care, added on top of Standard Precautions. The aim is to stop drug-resistant organisms moving from a resident to the hands and clothing of the people caring for them.

CMS says the precautions apply to a resident with either of these:

• A chronic wound or an indwelling device, whether or not any drug-resistant organism has been found. CMS names pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers as chronic wounds, and says a skin tear under an adhesive bandage does not count. Its device examples are central lines, urinary catheters, feeding tubes, and tracheostomies. A plain peripheral IV does not count.
• Infection or colonization with a drug-resistant organism that CDC targets, when contact precautions do not apply.

The residents stay on the precautions for the whole stay, or until the wound heals or the device comes out. They are not kept to their rooms. A resident with a feeding tube or a chronic wound can carry the sign for months, so a crew on a standing schedule meets the same sign on the same resident week after week.

CDC says the sign must name the type of precautions and the equipment, that a generic sign that only tells people to speak to the nurse is not enough, and that the sign may not state the diagnosis or the reason. CDC also says posting such a sign does not violate HIPAA or resident dignity. For a crew, that means the right question at the door is “what do we wear for this transfer?” and not “what does the resident have?”

Does a transport crew gown up?

A crew gowns and gloves when it does the kind of care the sign is about, inside the room. CMS lists eight high-contact activities: dressing, bathing or showering, transferring, providing hygiene, changing linens, changing briefs or helping with toileting, device care or use, and wound care. The list helps sort a typical pickup:

• Lifting a resident from bed or chair to a stretcher in the room. This is a transfer, and it is on the list. Gown and gloves.
• Handling a feeding tube, catheter bag, or trach during the move. Device care or use is on the list. CDC calls a gown and gloves the safest practice for any care or use of a device.
• Taking a wheelchair resident from the room door to the lobby without touching them. Nothing on the list applies. CMS says that staff who enter only to answer a call light, talk, or hand over medication would likely not need the precautions, and the same reasoning fits a crew that is only pushing a chair.
• Moving a resident from a wheelchair to a seat in a dining room or activity room. CMS says gowns and gloves are in general not recommended for transfers in common areas, where contact is shorter.
• Walking beside a resident down the hallway. CDC’s answer on therapy adds that gown and glove use is generally discouraged in hallways and other common areas.

CMS carves out two places where common-area transfers do count: a shared shower room and a therapy gym where close physical contact is expected. Neither is a normal pickup point.

Example: a crew arrives at 7:30 a.m. for three dialysis residents. One has a catheter and a sign on the door, one is in a wheelchair with a chronic wound and a sign, and one has no sign. The first needs a bed-to-chair transfer inside the room, so the crew puts on a gown and gloves for that move. The second is already in the chair at the nurses’ station, so the crew pushes the chair out without gowning. The third needs nothing beyond Standard Precautions.

Two limits apply to all of this. First, CMS and CDC wrote the guidance for the nursing home’s own staff, and neither the CMS memo nor CDC’s FAQs address outside transport crews. The facility’s infection program under F880 covers staff, volunteers, visitors, and “other individuals providing services under a contractual arrangement,” so the nursing home can reasonably tell a crew to follow its sign, and a crew should follow the instructions it gets on the nursing home’s premises. Second, CDC says it has not recommended enhanced barrier precautions in healthcare settings other than nursing homes. They end at the front door. Inside the van, Standard Precautions apply.

Enhanced barrier precautions and contact precautions are not the same sign

A contact precautions sign is stricter and changes the trip, so a crew should know which one it is looking at. CMS and CDC draw the line like this:

CMS’s own table says a resident with any drug-resistant organism whose secretions or excretions cannot be covered or contained is on contact precautions. CDC adds that enhanced barrier precautions are meant for drug-resistant organisms other than C. diff, which stays under the contact precautions rules.

A contact precautions resident can still ride. CDC’s guidance for these residents is to limit moving them out of the room to medically necessary purposes, and when a move is unavoidable to cover or contain the infected or colonized areas of the body. A dialysis visit is medically necessary. A crew that finds a resident with an uncovered, draining wound should stop and call the nurse before the transfer, not after. CDC applies the same limit on movement to a resident on airborne precautions, and the rules for that sign are in transporting a patient with TB or measles.

What to ask the nurse at handoff

Ask for the precaution and what it means for this trip, and leave the diagnosis alone. These questions settle most pickups in a minute:

• Which precautions is this resident on? Enhanced barrier or contact. The answer decides whether a hands-on transfer is gowned or whether the trip needs a conversation first.
• What equipment do we wear for this transfer? Gown and gloves are the minimum for the activities on CMS’s list, and CDC adds face protection when splashes or sprays are likely, such as during wound irrigation or tracheostomy care.
• Is any drainage covered or contained? If not, the resident may belong on contact precautions, and the nurse should say how it will be covered for the trip.
• Will anyone on our crew touch the wound or the device? Device care or use counts as high-contact care, so a crew that will adjust a tube or bag during the move needs the gown and gloves for that too.
• Where do we put the gown and gloves on and take them off, and where do they go? The facility knows its door and waste rules.

What the crew carries, and who pays for it

Crews carry their own gowns, gloves, and hand rub, and the company pays for what it requires them to wear. CMS tells nursing homes to keep PPE and alcohol-based hand rub within reach of staff, which means the facility’s own staff. New York’s Medicaid transportation manual makes the point at the vehicle level by requiring vehicles to be stocked with personal protective equipment for drivers in line with OSHA standards.

OSHA’s PPE standard, 29 CFR 1910.132, sets the employer’s side. The employer assesses the workplace for hazards, picks and supplies the equipment, trains each employee who has to use it, and provides it at no cost to the employee. A written crew rule helps here, for example “gown and gloves for any transfer inside a room that has an enhanced barrier sign, and no gown in common areas,” so that two crews do not make different calls on the same unit. Because protective equipment is changed before caring for another resident, a run with three signed residents needs three sets of gowns and gloves, not one.

Disposal follows CDC’s FAQ: most of this equipment can go out as routine non-infectious waste, and local or state rules may be stricter.

Cleaning your hands after the transfer

Take the gown and gloves off and clean your hands before you touch the van, then follow the usual wipe-down in the infection control guide. CDC says hand hygiene is recommended before and after resident contact, and the purpose of the whole practice is to keep organisms off the hands and clothing of the person doing the transfer. Gown and gloves come off first, hands next, and the steering wheel and door handles last.

Passing the sign on in HealthRide

When the nursing home tells dispatch that a resident has a barrier precautions sign, dispatch can message the driver in the driver app before the pickup, and the conversation stays in the company’s history. Push notifications never include passenger details, so the lock screen shows nothing about the resident. See team chat and the dispatch board.