Microbiology Laboratory1

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1 AppuL MIcROBIoLOGY, Jan. 969, p Copyright 969 American Society for Microbiology Vol. 7, No. Printed in U.S.A. Electronic Data Processing System for the Clinical Microbiology Laboratory DANIEL AMSTERDAM AND S. STANLEY SCHNEIERSON Departments ofmicrobiology, Isaac Albert Research Institute ofthe Kingsbrook Jewish Medical Center, Brooklyn, New York 0, and the Mount Sinai Hospital, New York, New York 009 Received for publication 8 November 968 Owing to the increased volume of laboratory services and the shortage of skilled medical microbiologists who presently spend up to 0% of their time in clerical matters, pragmatic applications of electronic sorting techniques and computers should be considered to alleviate this problem. Moreover, surveillance of the hospital community, with particular reference to changing patterns of microbial resistance and the distribution of potentially infectious pathogens, requires detailed information which can be readily supplied by electronic sorting analysis. Mark-sense and prescored Port-A-Punch IBM cards were used to: (i) analyze antibiotic susceptibility data; (ii) tabulate total test loads according to conditions set down by the American Society for Clinical Pathologists; and (iii) to prepare a bacteriological report on the surveillance of hospital infections. After proper sorting and analysis, the cards also serve as a convenient reference file in the laboratory for pertinent information recorded by either blackening the appropriate areas (mark-sense style) or pushing out the preperforated rectangular holes with a simple inexpensive board and stylus (Port-A-Punch). No one scheme can fulfill the requirements of all laboratories or purposes, but ideas contained herein might serve as starting points for the design of similar systems in other laboratories. The number of tests performed each year by hospital clinical laboratories is vast, and it is anticipated that it will continue to increase, especially where budgets for medical care exist. The volume of laboratory services is expected to increase 0 to 0% per year so that the total number of tests will double within a 5-year period (IBM Data Processing Application Manual, Laboratory Information System). This situation is further aggravated by the current continued shortage of skilled medical microbiologists and the fact that they spend almost 0% of their time in clerical work. Therefore, it is imperative that the pragmatic application of computers and electronic data processing equipment be considered and investigated in order to reduce the clerical work load, including: the repetitive transcription of patient name, number, location, and test data; laboratory searches for data; constant answering of phone calls; and the manual preparation of administrative test load reports now determined by hand-counting requisition forms. The purpose of any such system would be to best utilize the skill of the technologist to prevent wasting his I Presented in part at the st Meeting of the New York City Branch of The American Society for Microbiology, New York, February 968. training on clerical chores and to record, store, and tabulate test information in a more accurate manner. Inaccurate transcription of results would invalidate test data regardless of precise laboratory analysis. With local, state, and federal monies bearing an ever larger part of the burden of the cost for maintaining the health of the community, statistics will be required in greater detail by these agencies for individual patient accounting, since it is common practice today for many of the agencies to base their reimbursement on cost. Furthermore, information about the overall number and types of tests performed by the laboratory assumes ever-increasing importance for accreditation by various professional societies and organizations. The codified data can also support the laboratory director's requests for additional space, personnel, and new equipment. For these reasons, it becomes essential to know the total number of the different determinations performed and their distribution according to services, hospital location, and the source of payment, to equitably compensate hospital and laboratory. In addition to accumulating administrative statistical data, the system should provide an analysis of the accumulated laboratory data with 9

2 94 AMSTERDAM AND SCHNEIERSON APPL. MICROBIOL. - MSTAINSPECIES 560AU C i itnamef FIRST NAME ADMISSION NO MURSIM* STATION INCRON"e no. _ I' S, c44 c- -R: RD<R:) cr: cr cr)crd cr: -Pd -J=yM Facts IYAjo; < $ X awts 65 a"' AHT.Se-T-Is C?07$ Is FIG.. IBM mark-sense cardfor recording bacterial susceptibility to antibiotics. A,Be anc C represent additional CS coded spaces for antibiotics which might be necessary at sensitives a future date. S = R = resistant. FAST NAME FIRST NAME NO t ATION e ICOBIOE EY S I. LNU-vP9[X-;7;E --~-S-NURSIN_ C)I 0 7l 4 IS "'7 IS V 5i 7 SX} * $ *t 4 S CF SE 7 7 c 74 w7 4~ 445 ~ 4R44 ~ 4444TS ~ ~ S C STTSI WI. -. CULT NS SS OD. CULT CULT TB FUNGI SENS CC STAPH BACT WET AGG TB FUNGI PARAS 0&P BACT 4 a v a-7--f X - 8 S X ' X 7 0O S r C ~ L6 \ ; ;f. :-;;;.i 7 7 '6 5 A FIG.. Monthly print-out of total test record; test types are tabulated within specimen/source (SS) for each nursing station (NS). CC = urinary colony count.

3 VOL. 7, 969 STAPHYLOCOCCUS AUREUS INC IDENCE AND DISTRIBOTIOFREPORT Location - Spec./Source No. K I B U R I N E I 5 K B URI NE K A U R I N E URI NE K A UR NE K 8 C S F K4 UR I NE 8PUT 6 5 FIG. 4. Print-out of the incidence ofstaphylococcus aureus by specimen categories for each hospital location (nursing station) from which they were isolated. ELECTRONIC DATA PROCESSING SYSTEM particular reference to the antibiotic sensitivity patterns and epidemiological incidence of certain bacteria, e.g., Staphylococcus. The system to be described was designed to ultimately achieve the above aims, and this report covers the progress made toward the goals in two clinical microbiology laboratories. The storage, recording, and analysis of laboratory data in the scheme to be outlined is based upon the laboratory sharing the facilities of a central computer (at Mount Sinai Hospital) or electronic processing equipment (at Kingsbrook Jewish Medical Center) otherwise used for routine accounting procedures in the hosptial. Alternatively, outside organizations that perform similar services could be employed. Analysis of antibiotic susceptibility tests. In a previous report, Schneierson and Amsterdam () discussed the use of a specially imprinted prescored Port-A-Punch card suitable for the analysis of microbial susceptibility data. A mark-sense card utilized for this same purpose is illustrated in Fig.. The numbered extreme left quadrant is 6 l the area in which the mark-sensed information is converted into the informational format (holes) utilizable by the computer or electronic processing unit. In this design, only 7 antibiotic spaces are available, and there is an area available under each to designate the microbe's sensitivity or resistance. A separate card is required for each organism isolated from a single specimen. Additional information recorded for each specimen includes its source, bacterial species, and nursing station. All of the information categories are marked on the card with a special pencil in the designated areas according to a predetermined code. For nursing stations or bacterial species 0 through 99, coded slots are available; this does not hinder the number of possible choices. Once a month the encoded cards are processed by the central processing unit and a printed report is prepared. The report can be tabulated according to the number of susceptible or resistant strains to each antibiotic from each type of specimen for each bacterial species, the sensitivity record of antibiotics for bacterial species (not considering specimen type), or the sensitivity pattern related only to hospital location. Another report which could be scheduled might facilitate the statistical incidence and analysis of resistance transfer factor (R factor). Multiple resistance frequencies for any one or a number of species could be evaluated to uncover the possible existence of R factor, either in the hospital community or during the course of treatment of an individual patient. After the required sorting and analysis, the cards can also serve as a convenient laboratory reference file. Total test record breakdown. Figure illustrates a mark-sense card utilized at the Kingsbrook Jewish Medical Center to evaluate the test distribution according to hospital location, test category, or specimen category. The card is similar to the one shown in Fig., since the numbered columns at the left represent the area in which mark-sense information is converted into machine-sorting holed information. Test and specimen categories are those prescribed by the American Society of Clinical Pathologists and are: ordinary, tuberculosis, and fungus cultures; bacterial sensitivity testing; urinary colony count and staphylococcal phage-typing (not tabulated by the American Society of Clinical Pathologists, but included as "other tests"); smears for bacteria, acid-fast bacilli, fungi, and parasites; wet preparations for ova and parasites; bacterial agglutination; animal inoculation; drug level; and vaccine preparation. Nursing stations are entered according to a prescribed code from 0 through 99, but could be preprinted on another 95

4 96 AMSTERDAM AND SCHNEIERSON APPL. MICROBIOL. II:56655 is " 555,,s SIISSSIUSSggggggggg ggggggggggg gggggg I 5 islis s il IIIsss66 6 I55I II I II5I5 7 I5II5I ! x a a ~~ ~~~ - s ~ Sbd88 C8~ C D C-D D D D D COCOC0D CQD C0D DC0cDC.D0D OC-C0 -ZC0 C0DC0D C 9 CIDDC9I9DC)I CIDI9D9 CD 9 9C I 9 I DC9 I 9 I9DC~ CIC9 C:czczc=czcDC:>:c=cD~~C:>cDC=c:CD)>:C=C:CD CC=cD:c:>C=cD:c--c:C=cD~~~~))C:CD~C:CD>C=, C4cD4cD4C:c:>~~4D4D4C-cD4)4D4-cz-4~4>~~4)4cD4)4D-DJ D5cD5C:c:cD5>5D5)5C:cD5C=c5cD5)5cZc:C C5D C6:)c---X-6DcDC-6D6Dc6-c6D6Dc6D6Dc6C6:>6Dc6D6Dc6c6DCZ>C6=c6DCDC6D6Z>C6)c6:(--6 C D C7D g C7C7D C7 C7D c7d C7D c7d C7c7) C7D :c7d :C7D FIG. 5. Various IBM cards. Top to bottom: standard 508 card; prescored Port-A-Punch card; and two styles ofmark-sense cards.

5 VOL. 7, 969 ELECTRONIC DATA PROCESSING SYSTEM card such as the Port-A-Punch design (Fig. 5). The number of determinations in each test category is entered under the appropriate column. If no test was done, the zero area is blackened. If one or more tests are completed per specimen, the appropriate number is indicated. Once a month these cards are taken to the central processing unit, and a print-out is sent to the laboratory (Fig. ). According to the laboratory's requirements, the report can be based upon one of several major divisions, e.g., specimen source, nursing station, type of test, etc. Epidemiological surveys. The cards utilized for sorting and analyzing antibiotic susceptibility data or for codifying total test records can serve as a bacteriological report in the surveillance of hospital infections. At Kingsbrook Jewish Medical Center, we utilize the antibiotic card by blackening the last space from every specimen in which Staphylococcus aureus has been isolated. Once or twice a month these cards are processed by the unit, and a report (Fig. 4) is issued showing the total number of staphylococci isolated and their distribution according to ward locations and specimen sources. This information can serve as a basis for detecting the distribution of possibly highly pathological species within the hospital community. One need not limit this survey only to staphylococci, but the surveillance program can be extended to all species. Specification of the staphylococcal phage type can also be incorporated on the card. Considerations in the design of a system. Once the objectives of the sorting system are determined, the conceptual framework proceeds with the design of the input, the data processing card. Three basic cards are available from IBM (Fig. 5). They are: (i) the mark-sense card, (ii) the prescored card (Port-A-Punch card), and (iii) the standard 508 card. In general, 0 x 80 (800) bits of information can be stored on the 508 card, 0 X 40 (400) on the Port-A-Punch card, and only 0 X 7 (70) in the marksense style. Two additional horizontal columns are available in each format but are usually reserved for some nomenclature purpose (e.g., patient name, hospital number, etc.). Information recorded on the mark-sense card by blackening the designated areas with the special pencil is subsequently converted into rectangular notched holes for final sorting by the electronic processing unit (reproducing punch or summary unit). The additional step, that is, the conversion from mark-sensed information to the holed information is eliminated by using the Port-A-Punch or the standard IBM card. However, the standard card has a deficiency because a key-punch machine (IBM 06 or 00 key-punch) is required to enter the pertinent information. However, the preindented Port-A-Punch card seems to serve all purposes well since a simple inexpensive board and stylus can be used to press out the required information, and little skill is required to operate this unit. Another advantage of Port-A-Punch cards is that they can be processed through the electronic sorting equipment at a faster rate than mark-sense cards. Although the systems described above are initiated in the microbiology laboratory, they could eventually be incorporated into a more comprehensive plan in which test requests would be generated from the nursing station, either as hand-written laboratory requisitions which are centrally key-punched or as IBM cards themselves. Transportation of IBM cards with the specimen may present a problem because the card integrity ("do not bend or mutilate") must remain intact for proper processing. Other applications-bacterial identification system. The basis for the Adansonian method of classification (numerical taxonomy) requires a knowledge of all the phenotypic expressions or a statistically significant cross section of them. These can then be applied to monothetic (based on a few characters) classifications suitable for computers. Polythetic, or general-purpose classifications, contain and appraise many characters and are considered natural classification. In clinical microbiology laboratories, it may be imprudent to use the former method for routine classification. Recently, we () described a notched-edge card system for the identification of bacteria. This system could be easily transformed to electronic data processing equipment utilizing either the prescored Port-A-Punch card or the mark-sense card containing pertinent encoded characters of the unknown bacterium. A collator would then be employed to compare the unknown card with a known series, and a selection of the bacteriological species would be made. It is obvious that no one scheme can serve all laboratories or purposes, since each may have its own special requirements. However, the above designs have served well in our laboratories and might be used as starting points for new systems in other laboratories. ACKNOWLEDGMENTS The capable assistance of Lillian Waxstein and Bruce Brenner of the Electronic Data Processing Unit of the Kingsbrook Jewish Medical Center is gratefully acknowledged. LITERATURE CITED. Schneierson, S. S., and D. Amsterdam A punch card system for identification of bacteria. Am. J. Clin. Pathol. 4:8-.. Schneierson, S. S., and D. Amsterdam A manual punch card system for recroding, filing, and analyzing antibiotic sensitivity test results. Am. J. Clin. Pathol. 47: