Bad Habits Learned on the Job or Inadequate Medical School Training? Use of An Objective Standardized Clinical Examination to Assess Hand Washing Among Recent Medical Graduates.

Abstract

BACKGROUND: Hospital acquired infections are a major public health crisis, causing thousands of preventable deaths each year. Proper hand hygiene among physicians could potentially produce a dramatic reduction in the incidence of these infections; however compliance with hand washing guidelines has been shown to be suboptimal. One possible reason for this non-compliance is that medical students are not adequately trained in hand hygiene. The aim of this study was to determine the compliance level of proper hand hygiene among recent medical school graduates during a standardized patient encounter. METHODS: One hundred thirty-one new interns were evaluated during an encounter with a standardized patient (SP) portraying an individual with presumed thyroid disease. The session was part of an annual Patient Safety course given to incoming interns. We instructed interns to see the “patient” and perform a directed clinical examination. Each intern had the opportunity to use wall mounted Purell® alcohol-based hand rub dispensers located outside the examination room, or a sink with chlorhexidine soap located within the examination room. The SP and a course faculty member stationed outside the examination room evaluated interns’ hand hygiene technique that included: 1) washing hands before and after the examination; 2) use of soap and/or 3) use of alcohol-based hand rub. Following the encounter, interns were debriefed in small groups and given feedback about their performance. They were also instructed not to discuss the scenario with interns who had not yet completed the course. IRB approval was obtained. RESULTS: Of the 131 interns who were evaluated, 35.1% did not wash their hands prior to and 95.4% did not wash their hands after patient examination. 5 % rinsed their hands under water but did not use soap, and were considered to have not washed their hands for the analysis. Only 2.3% used alcohol based hand rub. Less than 1% used both soap and alcohol based handrub before and 0% used the combination after the patient encounter. DISCUSSION: Our results suggest that recent medical school graduates fail to use proper hand hygiene during patient encounters. We believe that the behaviors observed in this study parallel the performance in actual clinical settings since we used a SP in a realistic environment. These findings may underestimate the problem as the interns knew they were being observed, were not rushed, and had only one patient to examine. The lack of hand hygiene following the SP encounter suggests a lack of awareness about personal safety. The problem of hospital acquired infections is not unique to our medical center but rather is seen in alarming numbers throughout the world. Residency training programs should not assume incoming interns are proficient in hand hygiene and should provide mandatory training and evaluation to ensure compliance.