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Inside the Lab Microscopy and imaging, Quality assurance and quality control

How Serious Are You About Quality?

Danish physician Hans Christian Gram first experimented with alkaline dyes to differentiate bacteria in 1884, and his staining method remains a valuable tool in microbiology labs today. Highly accurate, clinically relevant Gram stain results can quickly support or change an infectious disease diagnosis and lead to effective therapeutic decisions. But, physicians need confidence in Gram stain quality – “anything less than accurate, clinically relevant results is below the community standard of care” (1). Therefore, the lab must make every effort to provide high quality, timely Gram stain results to enable an acceptable standard of care for our patients. For some labs, telemicroscopy may be a key component of the solution.

Without a robust training and competency system in place to help support these generalists, Gram stain accuracy can be less then 90 percent relative to culture results.

In my view, providing highly accurate Gram stain results is not always easy. In our evolving healthcare climate, labs are consolidating and forming core microbiology labs, leaving many satellite lab locations without a microbiologist onsite. General technologists with little microbiology experience are then responsible for preparing and interpreting Gram stains in these satellite labs, which is far from ideal. Some struggle with maintaining proficiency with this high complexity skill; they may have trouble making adequately stained slides, ending up with Gram-variable staining and vague results. Or, they may have difficulty identifying the bacterial morphology and thus hesitate to report the probable genus (2),(3),(4),(5).

Without a robust training and competency system in place to help support these generalists, Gram stain accuracy can be less than 90 percent relative to culture results. Needless to say, inaccurate interpretation is not without its consequences: revised reports, incorrect diagnoses or treatments, and ultimately, a poor outcome for the patient. Much effort is therefore needed to improve Gram stain proficiency in satellite labs and to provide continual monitoring as part of an ongoing quality assurance program. As difficult a task as it may sound, it is not impossible. In 2011, we successfully initiated a performance improvement plan using telemicroscopy in a satellite hospital lab; Gram stain accuracy was boosted to 97 percent and it has been sustained for the past four years!

However, according to a poll at the 2015 annual American Society for Microbiology meeting in New Orleans, very few labs are actually using telemicroscopy. In my opinion, they are missing the many advantages of this progressive technology:

  • easy and cost-effective consultation 24/7
  • real-time slide review with microbiology experts across vast lab networks
  • increased confidence and competency among less experienced technologists
  • improved accuracy and patient outcomes
  • confidential sharing of images using Windows IP configuration (no special software required)
  • digital image library that can be used in training programs
  • strengthened partnerships between core microbiology labs (or reference labs) and satellite labs
  • application to any lab department using microscopy (hematology, parasitology, urinalysis)
  • enhanced collaboration with public health officials during outbreaks and within bioterrorism preparedness programs.
Use of telemicroscopy to maximize the accuracy of Gram stain results is an effective way to achieve our mutual goals.

The cost of implementing a telemicroscopy system is minimal, especially when compared with the cost of revised reports or negative patient outcomes. With improvements in telemicroscopy and the advent of virtual Gram stain proficiency testing, this is absolutely the perfect time to incorporate digital technology into the microbiology lab. We all want to support the generalists in our satellite labs, share our expertise, and provide high quality, clinically relevant results for optimal patient outcome. Use of telemicroscopy to maximize the accuracy of Gram stain results is an effective way to achieve our mutual goals.

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  1. EJ Baron et al., “A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2013 recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM)”, Clin Infect Dis, 57, e22–e121 (2013). PMID: 23845951.
  2. RL Sautter, RB Thomson Jr, “Consolidated clinical microbiology laboratories”, J Clin Microbiol, 53, 1467–1472 (2015). PMID: 25253793.
  3. J Barenfanger, CA Drake, “Interpretation of Gram stains for the nonmicrobiologist”, Lab Med, 32, 368–375 (2001).
  4. KH Rand, M Tillan, “Errors in interpretation of Gram stains from positive blood cultures”, Am J Clin Pathol, 126, 686–690 (2006). PMID: 17050065.
  5. DD Rhoads et al., “Clinical microbiology informatics”, Clin Microbiol Rev, 27, 1025–1047 (2014).
About the Author
Linda Zuchowski

Linda Zuchowski is the Midwest Regional Microbiology Manager at Quest Diagnostics Laboratories.

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