Reducing Pathogen Transmission in a Hospital Setting. Handshake                   verses Fistbump: A Pilot Study          ...
AbstractHandshaking is a known vector for bacterial transmission between individuals (1-2). Handwashing has become a major...
INTRODUCTION        The handshake is an important social gesture that has been depicted in ancient Greekfunerary steles as...
reducing contact surface area, reducing total contact time between individuals, and protectingfingertips from pathogen exp...
Figure 3: Automated process of segmenting the palm and the coin (penny) surface areas. Thelatter was used as a reference o...
RESULTS The surface area of the palmar surface of the hand was found to be significantly greater than thefist (30.206 in2 ...
DISCUSSION        Many attempts to understand the routes of transmission of infectious agents have beenundertaken, and sev...
studies are needed to assess the level of significance between the handshake and fist bump in thisregard. An assessment of...
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Reducing Pathogen Transmission in a Hospital Setting. Handshake verses Fistbump: A Pilot Study

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This is a pilot study which examines the use of the fistbump instead of a traditional handshake in the hospital setting. In the hospital we use automatic doors, automatic sinks, and alcohol based hand sanitizer. However the rise of antibiotic resistant bacteria continues to increase. We propose ceasing handshaking within the hospital and opting instead for the fun fistbump will reduce the transmission of bacteria.

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Reducing Pathogen Transmission in a Hospital Setting. Handshake verses Fistbump: A Pilot Study

  1. 1. Reducing Pathogen Transmission in a Hospital Setting. Handshake verses Fistbump: A Pilot Study Paul A Ghareeb MD1, ThirimachosBourlai Ph.D.2, Nnamdi Osia2, Walter Dutton MS1, W. Thomas McClellan MD FACS1 1: West Virginia University School of Medicine, Department of Surgery, Division of Plastic Surgery2: West Virginia University Benjamin M. Statler College of Engineering and Mineral Resources
  2. 2. AbstractHandshaking is a known vector for bacterial transmission between individuals (1-2). Handwashing has become a major initiative throughout healthcare systems to reduce transmissionrates, but as many as 80% of individuals retain some disease-causing bacteria after washing (3).The fist bump is an alternative to the handshake that has become mainstream in popularity. Wehypothesize that implementing the fist bump in the healthcare setting may further reducebacterial transmission between healthcare providers by reducing contact time and total surfacearea exposed when compared to the standard handshake.
  3. 3. INTRODUCTION The handshake is an important social gesture that has been depicted in ancient Greekfunerary steles as far back as the 5th century BC (Fig 1). It is hypothesized that the initialpurpose of the handshake was to propose peace by demonstrating that the hand holds no weapon.In modern times, the handshake is a common way of greeting, offering congratulations, orcoming to an agreement. In the hospital environment, healthcare workers are commonlyconfronted with a handshake on a daily basis. Alternatives to the handshake during socialinteraction have been utilized throughout the years, but they have failed to become mainstream. Figure 1: “Handshake” - Priest and two soldiers, 500BC. Pergamon Museum Berlin In the modern healthcare setting, intense efforts have been placed on qualityimprovement measures to reduce complications and improve outcomes. Nosocomial infectionshave been identified as a major preventable complication of inpatient care, and numerouspolicies and protocols have been initiated to reduce the rate of these infections. One of the mostvisible initiatives to reduce nosocomial infections has been the hand hygiene initiative within theUS healthcare system. Hand to hand contact is a known vector for the transmission of infectiousdiseases, and efforts have been made to reduce this risk by encouraging frequent hand washing,as well as eliminating contact with contaminated surfaces such as door and sink handles(1,2,4,5,6). However, ensuring compliance with this initiative has proven to be challenging (7). One possible solution to help control the spread of infectious diseases in the healthcaresetting would be to eliminate voluntary hand-to-hand contact. Although this would accomplishthe goal of reducing transmission, it would neglect the social importance of the hand-to-handcontact that the handshake signifies. Therefore, the authors propose the fist bump as a safe andeffective alternative to the traditional handshake in this setting. The fist bump has gained recent notoriety as an alternative to the handshake after beingdisplayed in the mainstream media; the most notable example being President Obama’s use ofthe gesture (Figure 2). The fist bump is a simple, intuitive method of social interaction. Theauthors hypothesize that the fist bump will reduce bacterial transmission between individuals by
  4. 4. reducing contact surface area, reducing total contact time between individuals, and protectingfingertips from pathogen exposure. Figure 2: President Barack Obama and the first lady utilizing the fistbump at a political gathering, which was later dubbed “the fist bump heard around the world”.METHODSSurface Area Measurement 5 male and 5 female subjects were randomly selected from the WVU Department ofEngineering. Surface area of each subject’s right hand and fist was determined using thefollowing method (Figure 3). A semi-automated computer vision tool that computes the surfacearea (inches2) of human hands and fists was developed using both a visible and thermal camerato collect images of each. Each individual placed both their right hand palm down and fist whichwere then photographed. A penny was placed next to either a hand or a fist and used as areference since its true geometric area is known. Blob detection was first utilized to localize theregions of interest (ROIs of a hand or a fist), and then the ROIs were segmented using imagethresholding. The reference object (penny) was localized by computing the roundness metric RM= 4 * pi * area) / perimeter2, i.e. when RM is greater than a predetermined threshold the objectis considered a circle. Then, for each image we computed the penny’s diameter, as well as thehand or fist width or height in pixels. Finally, by using the formula (1) below, the surface area xof a hand or a fist (inches) was determined.
  5. 5. Figure 3: Automated process of segmenting the palm and the coin (penny) surface areas. Thelatter was used as a reference object to determine the exact area (in pixels) of the palm region.Contact Time Measurement Video footage of 18 different subjects (9 different subject pairs) was collected in order tomeasure the contact time of two main gestures between each pair, i.e. (i) hand shake and (ii) fistshake. The video frame rate was set to 30 frames per second. Each gesture was manuallyannotated frame by frame in order to determine the interval for which there was a skin contactbetween each pair of subjects for either gesture. The total number of frames for which contactwas present was counted, and the average contact time in seconds was computed.Bacterial Transmission Measurement Institutional Review Board approval was obtained prior to this investigation. Four 20x20cm plates were prepared using Mueller-Hinton Agar. Two healthcare workers, one male and onefemale, were assembled at a regional hospital. They were instructed to wash their handsthoroughly with soap and warm water for one minute. After drying, they proceeded to travelfrom the first floor lobby to the fifth floor surgical wards. Each subject performed the same tasks,such as pushing the elevator button and using door handles. Once present on the surgical wards,the subjects shook hands with 20 healthcare workers who were blinded to the purpose of thestudy. The subjects then returned to the hospital lobby, and their right hand was plated palm-down and held for five seconds. To assess fist bump transmission the same procedure wasperformed, with the exception that each subject plated their right fist instead of palm. The plateswere incubated at 37 C for 72 hours, and colony forming units (CFUs) were manually counted.Statistical AnalysisThe Student T Test was utilized for statistical analysis of differences in surface area. Colonycounts and contact time are reported as the mean.
  6. 6. RESULTS The surface area of the palmar surface of the hand was found to be significantly greater than thefist (30.206 in2 vs. 7.867 in2, p<0.00001). Furthermore, the total contact time of the handshakewas determined to be 2.7x longer than the fist bump (0.75s vs. 0.28s). Total colonization of the palmar surface of the hand was found to be 4x greater than the fistafter incubation for 72 hours (187.5 CFUs vs. 42.5 CFUs) (Figure 4).Figure 4: Representative plates illustrating bacterial growth of the handshake and fist bump.(Top left) right palmar surface of the hand after undergoing 20 handshakes, and (top right) thesame photo after utilizing a negative filter to illustrate colony density. (Bottom left) Bacterialgrowth of the fist after undergoing 20 fist bumps, and (bottom right) the same photo utilizing anegative filter to illustrates total density.
  7. 7. DISCUSSION Many attempts to understand the routes of transmission of infectious agents have beenundertaken, and several have been identified. Hand to hand transmission of bacteria has beenidentified as an important variable in efforts to reduce the spread of nosocomial infections withinthe healthcare setting (1,5,6). Importantly, Methicillin-Resistant Staphylococcus aureus (MRSA)is most commonly spread through direct contact between patient and providers (8). It has alsobeen demonstrated that door handles carry up to 5x more bacteria than push-plate door openers(4); up to 20.9% of door handles contain Methicillin-Sensitive Staphylococcus aureus, while upto 8.7% harbor MRSA (9). Methods to reduce this avenue of transmission have included strict hand-washingprotocols, alcohol based hand sanitizer, as well as the implementation of auto-opening doors andtouch-less sinks. Hand washing education has become a major initiative throughout healthcaresystems to reduce transmission rates, but as many as 80% of individuals retain some disease-causing bacteria after washing (3). Although hand-washing should be considered as an importanttool to reduce bacterial transmission it is not ideal due to lack of compliance, inconvenience, andvariability. Alcohol based hand sanitisers have been introduced in an attempt to supplement orreplace hand washing. However these sanitizers are not the panacea we had hoped they wouldbecome. Of particular note, is the rise of spore forming nosocomial infections such asClostridium Difficile, which are resistant to alcohol based hand sanitizers and on the risethroughout the United States (2). Sanitiser deficiencies highlight the need for a more effectivesolution such as a universal behavioral change regarding social contact within the hospital. The handshake represents an important social gesture and is frequently performed inhealthcare settings. While efforts have been made to reduce hand contact with potentiallycontaminated surfaces such as sinks and door handles, the handshake has been mostly preservedin this environment. This is most likely due to habit, social norms, the lack of a well acceptedalternative. Even still, several popular media outlets have reported on the fact that handshakesare being banned within certain groups, such as olympic teams and school athletic teams due tothe risk of pathogen transmission. Variables that lead to hand to hand transmission of pathogens include what you contact,where on your hand the contact occurs, and how long you contact the contaminated surface. Wehave demonstrated that the fist bump reduces both contact time and total surface area contactedby nearly 4x when compared to the handshake. Additionally the fist bump exposes the less useddorsal surface of the hand to a potential pathogen while protecting the fingertips and palm fromexposure. We believe the combination of these factors can explain the greater than 4x reductionin colonization when utilizing the fist bump. We surmise that the fist bump is an effectivealternative to the handshake in the hospital setting that may lead to decreased transmission ofbacteria and improved health and safety of patients and healthcare workers alike. This study was designed as a pilot to explore the potential harmful effects of the handshakewithin the healthcare system, and as such it has several limiting factors. The study is limited byour small sample size and as such we were unable to ascertain statistical significance; larger
  8. 8. studies are needed to assess the level of significance between the handshake and fist bump in thisregard. An assessment of virulence of the different strains that were observed would be useful tofurther delineate harmful bacterial transmission. Only 2D analysis of the fist and palm wasperformed for the study.Future studies may be useful to evaluate the 3D contact points betweenthe surfaces of the fist bump, as we believe the total contact area between two fists is muchsmaller than the total surface area involved. Viral transmission is thought to be commonlytransferred by skin contact, but was not assessed in this study. Furthermore, it is unknown at thistime if this observed decrease in bacterial transmission will lead to a decrease in hospitalacquired infections. Observing nosocomial infection rates before and after replacing thehandshake with the fist bump would be a useful way to determine if replacing the handshake canreduce nosocomial infections.ACKNOWLEDGMENTSWe would like to give special thanks to the Microbiology Department of Monongalia General Hospital, aswell asNeeruNarang and the Multispectral Imagery Lab (WVU) for their contributions in this work.References:1. Oniya MO, Obajuluwa SE, Alade ET, Oyewole OA. Evaluation of microorganisms transmissiblethrough handshake.African Journal of Biotechnology. June 2006. 5(11): 1118-1121.2. Boyce JM, Pittet D. Guideline for Hand Hygiene in Health-Care Settings: recommendations of theHealthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA HandHygiene Task Force. Infect Cont and Hosp Epidemiology. Dec 2002. 23(S12): S3-S40.3. Tambekar DH, Shirsat SD, Suradkar SB, Rajankar PN, Banginwar YS. Prevention of transmission ofinfectious disease: studies on hand hygiene in health-care among students. Continental J. BiomedicalSciences. 2007. 1: 6-10.4. Wojgani H, Kehsa C, Cloutman-Green E, Gray C, Gant V, Klein N. Hospital Door Handle Design andTheir Contamination with Bacteria: A Real Life Observational Study. Are We Pulling against ClosedDoors? PLoS One. Epub Oct 15 2012. 7(10):e40171.5. Aiello AE, Coulborn RM, Perez V, Larson EL. Effect of hand hygiene on infectious disease risk in thecommunity setting: a meta-analysis. Am J Public Health. 2008 Aug;98(8):1372-81.6. Duckro AN, Blom DW, Lyle EA, Weinstein RA, Hayden MK. Transfer of vancomycin-resistantenterococci via health care worker hands. Arch Intern Med. 2005 165:302-7.7. Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital.Ann InternMed. 1999. 130;126-130.8. Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touvenau S, Perneger TV. Effectiveness ofa hospital-wide programme to improve compliance with hand hygiene. Lancet 2000. Oct14;356(9238):1307-12.9. Oie S, Hosokawa I, Kamiya A. Contamination of room door handles by methicillin-sensitive/methicillin -resistant Staphylococcus aureus. J Hosp Infect. June 2002. 51(2): 140-3

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