A modest proposal: Ban handshakes in healthcare
C. diff may spread with friendly greeting
The ancient ritual of the handshake evolved in human dynamics in part as a way to instill trust by extending the weaponless hand. Ironically, this act of goodwill could put a frail patient’s life at risk if pathogens on the hands are exchanged as well as greetings.
That has raised a question that seems intuitively valid but could be surprisingly difficult to accomplish: Is it time to ban handshakes in health care settings?
Absolutely, says one who has embarked on something of a quixotic quest to break the shake, Mark Sklansky, MD, a professor of pediatrics at UCLA Medical Center in Los Angeles.
"I really believe it is the right thing to do for our patients and there are ways of doing this that do not compromise the doctor-patient relationship," he says. "Critics of this are concerned that it is going to further alienate patients from their doctors. If it is not replaced with any warmth and compassion in other ways, then yes, I think there is a risk of that. But there are many other ways we can express the same kind of sentiment that we do currently with a handshake."
Sklansky concedes that a hand shake may have a calming effect on patients and family members, engendering trust and reassurance. Seen in that light, banning handshakes could raise a marginal patient safety issue in its own right, but the benefits of a ban far outweigh the risks, he notes. In any case, it makes little sense for health care workers who are constantly trying to decontaminate their hands to complicate the issue by shaking them with colleagues and visitors between patients.
"There are clear benefits to the handshake but we feel a health care setting that is a concentration of vulnerable patients and pathogenic organisms is not the right place to be continuing this gesture," he says. "We know that it is a gesture that transmits disease."
Transmission of C. diff by handshake
Several research examples were cited in a recent review paper1 Sklansky and colleagues did on the issue: "The infectious risk of the handshake has been described in the medical literature since the early 20th century. Multiple studies have demonstrated that the handshake can and does transmit pathogens,2-4 and widespread hand hygiene policies have been predicated on the well-established link between hand transmission of pathogens and disease. Clostridium difficile spores have been demonstrated to be transmitted via the handshake"
Indeed, C. diff may be the best single argument for a handshake ban. It has emerged to epidemic levels in a particularly virulent strain (NAP1) and its spores have been found clinging to hands even after infection preventionists have thrown everything at them but the patient sink. Most hospitals switch from alcohol hand foams to soap and water for known C. diff patients, but the problem is that even soap is surprisingly ineffective at spore removal. In a 2013 study, the few solutions found even partially effective against C. diff (greater than one log spore reduction) included a heavy-duty Borax brand name product and an industrial solution designed to remove printer’s ink.5
It is widely acknowledged that alcohol hand rubs provide little protection against C. diff. In the aforementioned handshake study4 a variety of alcohol hand cleaning solutions were used by volunteers whose hands had been inoculated with C. diff spores. So many residual C. diff spores remained on the volunteers’ hands that they could be easily transferred by a handshake with another person. A mean of 30% of the residual C. diff spores were transferred per handshake.
More research needed to drive change.
While the research certainly underscores the risk of handshakes contributing to health care associated infections, a handful of studies will not likely be sufficient to drive broad change. "In terms of large scale and institutions adopting this, people are going to want more data," Sklansky says.
In that regard, he plans to propose some type of handshake ban to his colleagues at UCLA, perhaps limited to an ICU setting. "In NICUs and other places doctors may have to do rounds on 10 to 20 patients in one day," he says. "You see the patients, the families at the bedside and it is just not practical to wash your hands before and after every handshake. If you wash your hands but then shake someone’s hands [they may become] contaminated again."
If given the green light on the idea, Sklansky plans to research the attitudes of patients and caregivers about banning the practice and also look at the incidence of infections before and after a ban. In any case, a handshake ban would have to be accompanied by the appropriate signage and patient educational materials to make it clear it was being done in the name of infection prevention.
Even in the name of that higher calling, it’s hard to overstate how entrenched handshaking is in human relations. As Sklansky has occasionally attempted to avoid handshakes in the hospital he has sometimes drawn some chilly reactions.
"I’ve tried this intermittently over the years and it’s always been a challenge — the stigma puts me in a difficult position," Sklansky says. "I’m hoping that more attention to this will legitimize this issue and concern and people will recognize it is actually in the patient’s best interest. We are doing it for their sake. Many patients understand when I wash my hands and don’t shake their hands, but I have certainly found after we published this paper that there is actually a fair amount of concern from the lay public as well as people within the profession that this is not a good [idea], it’s not going to work — the handshake is just too socially engrained."
Indeed, the practice is so widely accepted in our culture that Sklansky compared the challenge of banning it to fighting Big Tobacco. Since the first Surgeon General’s report on smoking in 1964 — when some 40% of adults (and their doctors) smoked — smoking has plummeted to some 18% and bans are widespread. "Removing such a deeply embedded cultural custom from social situations has involved, beyond formal bans/regulations, widespread media and educational efforts, as well as the development and promotion of effective alternatives, such as nicotine gum," Sklansky notes in the paper.
Bow, nod and fist bump?
So what would be the effective alternative to handshaking, something that would imbue the same warm feeling without risking downstream infections?
"Personally, I like putting your hand on your heart, and sort of nodding your head with respect to each person with a smile, he says. "I think once people start trying this stuff and actually banning the handshake, people are going to find that they can communicate warmth and compassion — and maybe actually improve the connection that we have now that is sometimes sort of perfunctory with a handshake."
Other alternatives from various cultures include a wave of the open hand, a slight bow of the head, and the yoga gesture of placing the hands, palms together, against the chest and tilting the head forward.
In a hip reference to rap and sports culture, one group advocates the "fist bump" as a good alternative to shaking hands. They actually tested their hypothesis, finding that the surface area of the palm was much bigger than the knuckles, the total skin contact time of the handshake was 2.7 times longer, and colonization of the shaken hand was four-fold greater than the tapped knuckles.6
"Implementing the fist bump in the healthcare setting may further reduce bacterial transmission between healthcare providers by reducing contact time and total surface area exposed when compared with the standard handshake," the authors concluded.
- Sklansky M, Nadkarni N, Ramirez-Avila, L, et al. Banning the handshake from the health care setting. JAMA Published online May 15, 2014. doi:10.1001/jama.2014.4675
- Döring G, Jansen S, Noll H, et al. Distribution and transmission of Pseudomonas aeruginosa and Burkholderia cepacia in a hospital ward. Pediatr Pulmonol 1996;21(2):90-100.
- Hamburger M Jr. Transfer of beta hemolytic streptococci by shaking hands. Am J Med 1947;2(1):23-25.
- Jabbar U, Leischner J, Kasper D, et al. Effectiveness of alcohol-based hand rubs for removal of Clostridium difficile spores from hands. Infect Control Hosp Epi 2010;31(6):565-570.
- Edmunds SI, Zapka C, Kaspar D, et al. Effectiveness of hand hygiene for removal of Clostridium difficile spores from hands. Infect Control Hosp Epi 2013; 34:302-305.
- Ghareeb PA, Bourlai T, Dutton W, et al. Reducing pathogen transmission in a hospital setting: Handshake versus fist bump: A pilot study. J Hosp Infect 2013;85(4):321-323.
