Hand Shake Free Zone: Bad Joke or Clinical Necessity?

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After the 2013 publication by Ghareed et al. (see BIJC post here) on fist bumps in the health care setting in order to prevent transmission of pathogens JAMA now joins in the discussion. Sklansky M et al. published a viewpoint on the banning of the handshake from the health care setting. In their paper they point out that the hands of health care workers often serve as vectors for transmission of organisms and disease. The fact is highlighted that adherence of health care providers with hand hygiene remains rather low and that handshakes have shown to be able to transmit pathogens. In their article they draw parallels between the ban of handshakes in a health care setting and the ban of smoking in public places and finally offer a variety of alternative greetings methods like: the ‘hand wave’ and placement of the right palm over the heart, or the Namaste gesture also practiced in yoga around the world.

This offers an interesting viewpoint worth reading indeed but I might add a few remarks and questions to this article. Apart from the fact that I still struggle to follow the link between hand shakes and smoking in public and would like to highlight following:

– The link between pathogen transmission by handshakes and consecutive patient outcome is totally unclear. At this stage there is no evidence indicating that handshakes themselves impose a serious threat to patients.

– Banning handshakes in hospitals might sound like a good idea, but the main problem remains unaffected. Multi-resistant bacterias are the logical result of inappropriate prescription and usage of antibiotics. It certainly is advisable to prevent the spread of these pathogens but it would be better to prevent their man made evolution.

– Physical contact with patients in the ICU is an essential part in patient care (e.g. nursing or medical examination) and socialising might be even more important when you’re unwell. Of course contact isolation has been found to help prevent the retransmission of pathogens. We tend to forget though that all these measures at the same time might have other unintended consequences. From 1999 to 2003 three articles showed that patients in contact isolation got half as many visits from health care providers resulting in 20% less contact time (Morgan DJ et al. Infect Control Hosp Epidemiol. 2013;34(1):69-73).  Remarkably, similar effects were found also a decade later. Evidence has continued to accumulate that patients on contact precautions may experience worse outcomes, including more delirium, more depression, worse discharge instructions, and less smoking cessation counselling.
Withholding a handshake sounds simple but might actually further contribute to patient’s isolation and there is also some research out there actually showing on how important this gesture actually might be (Dolcos S et al. J Cogn Neurosci 2012 Dec;24(12):2292-305).

The first sentence of the Conclusion by Sklansky et al. reads as follows: ‘Banning the handshake from the health care environment may require further study to confirm and better describe the link between handshake-related transmission of pathogens and disease.’… I couldn’t agree more!

I think we might have to be very careful on already starting to talk about ‘hand shake free zones’ as long as there are so many unanswered questions. Many things have been done in the past to prevent infections and finally have been proven to be completely inutile (e.g. changing peripheral lines after three days, read post here). Maybe we she focus more on avoiding overprescribing antibiotics instead.

What do you think…?

Sklansky et al. JAMA. Published online May 15, 2014. doi:10.1001/jama.2014.4675

The picture displayed above is take from the New York Times

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