Telemicroscopy: Applying Technology to Solve an Old Problem

The Gram Stain

Everyone knows that the Gram stain is an essential microbiological method which aids in the differentiation of bacteria. When a specimen is sent to the clinical microbiology laboratory for culture, the Gram stain result is frequently the first information provided to the clinician. It is used to first determine a) if infection is present and b) what type of infection (i.e., gram positive vs. gram negative? monomicrobial vs. polymicrobial?). Furthermore, if organisms are observed in a normally sterile fluid/tissue (i.e., blood, cerebral spinal, fluid, cardiac tissue, etc.) the Gram stain result can be a critical result. More importantly, the Gram stain result often drives patient care. 

The Issue

Although the Gram stain is an essential clinical tool, many laboratories struggle to maintain competent technologists, especially on off-shifts or in laboratories that lack microbiology expertise (generalists). The need for second review is common when performing Gram stains as they are often subject to variability due to inconsistent staining techniques, antibiotic pressure, as well as artifacts. Even under best case scenarios, Gram stain interpretation can be challenging and may require multiple reviewers. 

The Solution

Telemicroscopy offers an easy to use and relatively inexpensive solution to provide formal and informal second opinions to various sections of the laboratory (microbiology, hematology, pathology). With the proper tools, telemicroscopy allows Gram stain interpretation from anywhere there is internet access.  Every hospital laboratory has a microscope and a computer with internet, so the only item that may need to be purchased is a microscope camera (≥$5,000). There are also various microscope adapters available for phone cameras that provide equal results for less capital (≥$90). The microscope adapter encases the smart phone and then fits into the eyepiece of most microscopes.

Telemicroscopy utilizes technology to improve diagnostic accuracy, by providing expert consultation for technologists who are uncertain of their results. Telemicroscopy allows laboratories to “present” still or live images to a reference laboratory via a web-based software application such as Skype (or FaceTime if using an iPhone).

About Geisinger Medical Laboratories Telemicroscopy Program 

Geisinger Medical Laboratories is an eight hospital integrated health service organization, serving >2.6 million residents throughout 46 counties in Pennsylvania. Geisinger Medical Center serves as the reference laboratory for 4 minimal laboratories (Gram stain reading, no culture work-up) and 2 partial laboratories (Gram stain reading, limited culture work-up). The Telemicroscopy program consists of presenting still or live images [Olympus BX40, BX41 microscope, Nikon cellSense software (version 1.7.1)] to the reference laboratory via Skype [Logitech 920 camera (version 2013)]. The telemicroscopy result, which is a consensus finding, is manually recorded and followed up with culture review to determine patient impact. 

The Outcome

We evaluated the effect of implementing a telemicroscopy program on patient care.  A retrospective look back at our telemicroscopy data showed that nearly 40% of consults resulted in a change to the original interpretation. The consensus Gram stain result correlated with culture 85% of the time. Overall, 49% of the cases assessed by telemicroscopy were impacted by the consult. Of which, patient care was positively and negatively impacted in 72% and 28% of cases, respectively.

The Conclusion

Gram stain consultations via telemicroscopy from remote hospital sites can improve patient care. Telemicroscopy offers a simple, inexpensive, and innovative approach to providing expert consultation services to off-shift or inexperienced staff. This is also a great way to promote interdepartmental consultation and collaboration (i.e., between microbiology and hematology or pathology).

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Image 1. Telemicroscopy via traditional microscope camera. Microscope with camera attached and computer screen showing Gram stain.
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Image 2. Telemicroscopy via s mart phone. Close up of microscope adapter attached to microscope. Image of Gram stain displayed on phone screen.

References:

  1. Microbiology Strong: Enhancing Microbiology Services and Technical Support in an Integrated Laboratory System. ASCP.  Las Vegas, Nevada. September 2016. Oral presentation.
  2. Martinez, R.M., Shoemaker, B.C., Riley, J.A., and Wolk, D.M. 2016. The TeleGram of the 21st Century: the Digital Gram Stain. American Society for Microbiology (ASM) General Meeting. Boston, MA. Poster presentation.

 

Martinez Headshot-small 2017

-Raquel Martinez, PhD, D(ABMM), was named an ASCP 40 Under Forty TOP FIVE honoree for 2017. She is one of two System Directors of Clinical and Molecular Microbiology at Geisinger Health System in Danville, Pennsylvania. Her research interests focus on infectious disease diagnostics, specifically rapid molecular technologies for the detection of bloodstream and respiratory virus infections, and antimicrobial resistance, with the overall goal to improve patient outcomes.

 

 

The Importance of Manual Urine Microscopy

Research presented today at the National Kidney Foundation spring clinical meeting indicates that manual microscopy surpasses automated analyzers when assessing kidney injury. The abstract is titled “Manual Microscopy: Not a Lost Art” and says, in part: “In this study, we examined if a significant difference exists between the reported ranges of granular and muddy brown casts using manual microscopy as compared to an automated urine analyzer in an acute kidney injury cohort.”

According to one of the abstract’s authors, Dr. Sharda, “What our research has been able to show so far is that the automated system under reported the value of granular casts in our patient cohort of acute kidney injury. The automated system still has utility as a screening test, but manual microscopy should be done in all cases of abnormal kidney function, as accurate quantification of casts could have some prognostic benefit to patients.”

The poster is available online. The authors are currently writing a paper on their research; their contact information is here.