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Handshaking Spreads Germs. Get Over It.

 |  By cclark@healthleadersmedia.com  
   July 31, 2014

Evidence is mounting that alternatives to hand-to-hand contact between and among healthcare workers and sick people are necessary to curb the spread of infection.


When patients visit Mark Schenkel, MD, in his West Hills, CA family practice, they're greeted by signs posted in the waiting area and inside each exam room: "Don't Be Offended. Handshaking Spreads Germs."

That's to explain why he and his staff no longer shake the hands of patients and their family members. He doesn't want anyone to feel insulted or think he's being rude.

The policy he set a few weeks ago is an experiment to see how well staff and patients adjust to his "hands-off" approach to reducing infections, since several research studies show handshakes can transmit illness-causing organisms.

"I explain to them, 'I'm not being like that germaphobe Howie Mandel,' " he says, referring to the actor-comedian who is publicly candid about his struggle with obsessive compulsive disorder.

But evidence is mounting that hand-to-hand contact between healthcare workers and sick people spreads disease, Schenkel says. Banning the handshake in his practice is one way he might help prevent spread of disease.

Ban the Handshake

It all started in June with a viewpoint piece published in JAMA, in which Mark Sklansky, MD, a pediatric cardiologist at Mattel Children's Hospital UCLA and colleagues, admonished fellow clinicians to "ban the handshake" from healthcare settings to keep nosocomial infections down, Schenkel says.

Sklansky proposed setting up "handshake-free zones" especially in high-risk areas of acute care hospitals, so that patients and family members wouldn't take things personally. As an alternative, he suggested the fist bump, a hand wave, or even a bow.


Infection Prevention Effort Targets Hospital Handshakes


Sklansky himself hadn't done any research on the topic, but he wrote his opinion piece simply to help put two and two together for his fellow clinicians. Multiple studies, he reasoned, "have demonstrated that the handshake can and does transmit pathogens." Disease-causing germs love healthcare settings. Yet healthcare providers wash their hands when they're supposed to, in-between every patient contact, only 40% of the time, he wrote.

Heaven forbid a greater recognition that in fact, it may be doctors and nurses who are making patients sick, or even sicker, he says.

As the world turns, it happens that Schenkel's brother and Sklansky are neighbors. At a party hosted by Schenkel's brother just after the JAMA paper was published, a jocular Sklansky "came in fist bumping and elbowing people to greet them," Schenkel recalls.

Sklansky's JAMA piece received enormous attention on Twitter, with some physicians saying he had a good point, and others saying he was crazy or silly, because the handshake was an important component of doctor/patient trust.

Earlier this month, Sklansky even penned a commentary for The San Francisco Chronicle, in part to explain and defend himself. "I was intrigued," Schenkel says. "I said I'd be willing to let my office be a beta site to see what patients' response would be."

Research published this week in the American Journal of Infection Control appears to provide scientific evidence behind Sklansky's hands-off proposition, and Schenkel's modest experiment.

Researchers at Aberystwyth University in Wales immersed a donor participants' sterile-gloved hand into a dense culture of E-coli (a non-pathogenic strain), and after it was dry, exchanged greetings with recipient participants, who also wore sterile gloves.

They tested the handshake, the high five, and the fist bump in a crossover design so that each "donor" and each "recipient" tested all greetings, eliminating potential for bias among the volunteers.

 When the results were in, nearly twice as many bacteria were transferred during the handshake compared with the high-five, but the fist-bump "consistently gave the lowest transmission." The authors concluded: "adoption of the fist bump as a greeting could substantially reduce the transmission of infectious disease between individuals."

I thought Sklansky would feel vindicated, after the slings and arrows he absorbed for his proposition. And he was.

A Hospital Trial?

Now, he says, he's working with the UCLA School of Public Health to demonstrate how a handshake-free zone could work. Although he says that may be a long ways away.

It would, of course, need institutional review board approval, and he acknowledges, would surely meet resistance. "People are very reluctant to dispense with this [handshaking] custom, even in hospital settings. But as more attention is brought to how important hand hygiene is, in terms of transmitting disease, I think more people will realize that the handshake is not the right gesture we should be using."

Ronald Reagan UCLA, a 540-bed hospital with 100 additional pediatric beds that is the Mattel Children's Hospital, would be a great place to test the idea.

The Centers for Medicare & Medicaid Services has found that of six types of infections that pervade hospital settings, Ronald Reagan UCLA is significantly worse than national benchmarks in two, Clostridium difficile and catheter associated urinary tract infections.

Sklansky was not aware of Ronald Reagan UCLA's standing, but says his point is not to target his own organization, as much as it is to target infection control policy across the nation.

For now, Sklansky is not taking his own medicine.

"Sometimes I will say to a patient or a colleague, 'No, I'd rather not shake your hand,' because of the risk of infection, but I have my work cut out for me then to explain. It's not what people are expecting. I don't want to insult my patients." So usually, he says nothing, and proceeds to shake peoples' hands.

"The real solution is to take the onus away from the healthcare providers, and get the support of public policy and the community. That's the bottom line," he says.

Mary Lou Manning, president-elect of the Association of Professionals in Infection Control and Epidemiology, says she's glad Sklansky's idea is getting attention.

"We've known for a very long time that hands are the number one way that infections are spread," says Manning, associate professor at Thomas Jefferson University School of Nursing in Pennsylvania.

"We're a long, long way away from banning the handshake. But maybe some hospitals are having an expanded conversation because of studies like this, and the media attention they've been given. What I love about this is that we're really creating a conversation, and a little controversy too, which is always good.

"What we do with this information," she says, "is what's next."

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