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Stepwise Success

Use the Gram Stain

Published May 24, 2013 6:18 AM by Scott Warner

In microbiology we learn to use the Gram stain results of a direct smear to check specimen quality (usually by a count of squamous epithelial cells) and any predominating organisms (e.g. lancet shaped Gram positive cocci on a sputum) that suggest what to work up.

All good micro techs use the Gram stain. Intracellular organisms are an immediate clue of what’s causing an infection. If an organism is seen on the Gram stain and not seen on the plates, it could indicate that the patient is being treated, making the organisms non-viable. Gram staining urine specimens can give hints of certain organisms, such as Aeromonas. It’s one of the first steps in the detective job of the microbiology tech, to tell the doctor what’s causing an infection and how to treat it.

But the Gram stain can also be used to educate and connect with other front line staff. It can be used to elevate our profession and status as a clinical resource, instead of being seen as button pushing phlebotomists.

When a wound culture direct smear shows many squamous epithelial cells and what appears to be mixed skin flora, it’s a chance to talk with the nursing staff about how the specimen was collected. It’s a chance to talk to the pharmacy about how the patient may already be treated. And it’s a chance to check the chart and talk to the physician about why the culture is important e.g. MRSA.

I reviewed a chart of a suspected pneumonia patient, and in the H&P the physician had noted “Gram stain shows many white cells and Gram positive organisms.” This was correct to a point; the reason I reviewed the chart is because the plates were being worked up for Haemophilus. The Gram stain report also reported intracellular organisms and many Gram negative cocci. Why didn’t the H&P accurately reflect the recent report? Why didn’t the admitting doctor see this original report and notice the discrepancy?

All good chances for us to use the Gram stain to improve patient care.

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2 comments

Leslie,

Thanks for commenting! I think that is a GREAT suggestion. I haven't seen such an article myself. The interpretive aspect of laboratory medicine is something we should be more involved with; often physicians will make assumptions based on experience or expectations. There is so much we can do, and it only helps the patient when we can connect the dots. I'll keep you posted if I find anything!

Scott Warner June 4, 2013 6:01 AM

This was a great article.  Do you have a little more in depth article that I could use to give out to the techs that I work with that would be good information for them to use.  We outsource our Micro, but on occasion may have to do stat gram stains and have to interpret our reference lab's micro reports.  On many occasions they don't understand what they are turning out and don't know that their gram stains and/or cultures are critical.  Many of them have not had extensive micro training.  Let me know!  Thanks!

Leslie Richendifer, Lab - Staff tech, Mountain View Regional Hospital June 2, 2013 9:09 PM
Casper WY

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    Scott Warner, MLT(ASCP)
    Occupation: Laboratory Manager
    Setting: Critical Access Hospital
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