Diagnostic testing is sometimes thought of as a puzzle to be solved. Each piece must fall into place throughout the testing process for patients to receive their results. To begin with, the specimen must be collected properly, transported appropriately, and stored under the right conditions. An order must be placed with the intended test clearly indicated and with relevant patient information included.

So what happens when a piece of the puzzle is missing? ARUP’s Exception Handling (EH) Department steps in to investigate any missteps, promptly solve the problem, and enable the performing laboratory to proceed with testing. One of the first stages of EH’s investigation process is to “put a test on Except,” which indicates the specimen or order has an issue that must be resolved.

Multiple EH teams exist at ARUP, including specialized teams for Infectious Disease, Genetics and Oncology, and Referral Testing. Issues involving specimens not intended for one of these specialized areas are handled by Central EH (CEH).

“We’re essentially the problem-solving department for the company,” said Cidney Collett, laboratory client support specialist (LCSS) trainer. “Any issue that is identified by the performing laboratories or by Specimen Processing is sent to Exception Handling to be resolved.”

The Except process is critical to laboratory operations and enables ARUP to test specimens that can’t be tested following standard processes. For example, red blood cells in a specimen might have broken down during transport, or the volume of a specimen may be insufficient for the requested testing. A test order could have been entered incorrectly. Paperwork could be missing or provide unclear information.

“We’re opening up possibilities to be able to test specimens that otherwise couldn’t be tested,” said Ally Ledesma, a supervisor in CEH. “This is especially helpful in situations with complicated test orders for a patient.”

Ledesma reported that approximately 15,000 Excepts are processed each month in CEH. Without CEH’s involvement, these specimens would not be tested. ARUP tests approximately 2.1 million specimens per month, which means that roughly 0.7% of specimens are put on Except by CEH. Although Excepts are rare, CEH’s handling of Excepts ensures that more testing can be performed.  

The process that CEH follows to investigate and resolve an Except is complicated and varies from case to case. The first step is always to see if the issue can be resolved internally, without contacting the client.

“Trying to find internal resolutions is our priority,” Collett said. “This could involve substituting one sample with another sample from the same patient or contacting the lab to see if they can reroute samples.”

If there is no internal solution, the laboratory client support technician (LCST) must contact the client for resolution through ARUP Connect™, a secure online platform that helps clients manage the testing they send to ARUP, or by phone.

Some of the most complicated scenarios that CEH handles are “four-by-fours.” In these situations, it is unclear which client sent the sample to ARUP, and while working to resolve the issue, CEH uses a miscellaneous client ID, 4444, in its case documentation. Four-by-fours occur when clients have not included the submitting facility’s information in packing lists, labels, or test orders.

Anna Blaes, an LCST, said, “The process involves sorting through paperwork, checking bag images, and looking at orders under the same patient if you have patient information. Hopefully something on the label or paperwork can give me a good indication of who it might have come from.”

Blaes added, “If the specimen doesn’t have a label, that’s also a problem. We don’t know what it is or when it was drawn. We don’t know when it goes out of stability, or what test the client wants. It’s a huge mystery.”

Of the 15,000 Excepts CEH handles per month, approximately 210 are four-by-fours, Ledesma said.

To ensure that LCSTs are well prepared to tackle challenges like these, all newly hired LCSTs go through 10 weeks of training before working independently.

Collett said that CEH’s training program is intensive and personalized. Each trainer is dedicated to one trainee throughout the training process and works alongside that trainee one on one.

“Ten weeks is necessary because we see so many different cases in Exception Handling,” said Collett. “It gives trainees time to exercise problem-solving and get comfortable making judgment calls. It’s like a muscle that needs to be exercised to be a comfortable and strong technician when they hit the floor.”

Collett said that during their training, LCSTs learn and practice three main types of tasks: triaging, client communication, and labeling. Triaging is the problem-solving part of the job and requires LCSTs to handle samples in the laboratory, document any issues, and search for internal solutions. If no internal solution is found, then the client needs to be contacted. Labeling takes place after the issue has been resolved and the sample needs to be routed for further testing or for storage.

Blaes recently graduated from the CEH training program and now handles Excepts independently. She was surprised by how many complex cases she saw during training.

“There were some things that even the trainers had never seen,” Blaes said. “We’d pull up an issue and they’d say, ‘I’ve been here for 16 years, and I’ve never seen that.’ Then, we’d methodically break down the process of problem-solving and come to a solution.”

CEH’s trainers aim to create a supportive, collaborative environment and encourage trainees to ask questions and develop their problem-solving skills. “In training, we create structure, but at the same time, it’s a bit relaxed,” Collett said. “We try to foster a very comfortable atmosphere to encourage people to ask questions.”

Blaes said that she enjoyed her training program and the people she works with. “The type of work we do lends itself to creative thinkers and people who are very detail oriented. Everyone here is also very friendly. In our downtime we have great conversations, and it’s easy to make fast friends.”

Collett’s role on the training team is unique, as she is the only floor trainer. She oversees employees who have graduated from training and answers questions about complicated cases, offers retraining, and observes trends on the floor.

"It’s really a never-ending process,” Collett said. “We care about constant improvement and continued education throughout an LCST’s time in Exception Handling."

This commitment to continuous improvement and education is not only evident in the training process, but also in CEH’s quality assurance procedures. Tracy Dinsdale, an LCSS, is also CEH’s dedicated quality assurance specialist. An LCSS usually helps LCSTs with more complicated cases that need extensive investigation, but Dinsdale’s role is focused primarily on quality assurance.

“One of the Five Pillars of ARUP Culture is continuous improvement,” Dinsdale said. “We identify issues and resolve them so they don’t happen again.” Dinsdale also pointed out that the quality process is a necessary component of ARUP’s many quality accreditations, including the ISO 15189 certification.