Delta Check

Calculation Guide

© National Technology 2017, All Rights Reserved

By Senior Scientific Researcher, Asmaa Taher
Table of Contents
Definition ........................................................................................................................ 2
Purpose ........................................................................................................................... 2
Delta Check Research Studies ......................................................................................... 2
CAP Q-Probe................................................................................................................ 2
Study conditions...................................................................................................... 3
Observations ........................................................................................................... 3
Recommendations .................................................................................................. 4
Actions taken .......................................................................................................... 4
Findings ................................................................................................................... 6
UAMS: University of Arkansas for Medical Science .................................................... 9
Findings ................................................................................................................... 9
Keep in mind…………………………………………………………………………………………………………10
How to Calculate Delta Check Limits? ........................................................................... 11
Example..................................................................................................................... 11
References .................................................................................................................... 12

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Definition
The Delta Check is a measurement of the difference between a patient’s sequential test
results, where a larger than expected interval change in results may indicate a testing
problem associated with either the former or the current specimen and prompt an
investigation before results are reported.
Delta check can be expressed as the absolute or the percent difference between two
consecutive results.
 Absolute value are calculated as the difference between the larger and smaller result.
1. Δ = X-x
 Percent delta are calculated as the difference between the larger result and the smaller
result divided by the smaller result.
2. Δ% = (X-x)/x
Where: X is the larger result / x is the smaller result

Purpose
1. Delta checks are widely used in clinical laboratories as a patient-based quality
assessment tool to detect errors associated with:
a. Specimen collection
b. Analysis
c. Reporting problems
2. Provides a safety net for identifying testing errors that might otherwise go
unnoticed.
3. An important component of auto-verification procedures that improve the
laboratory’s efficiency

Delta Check Research Studies

CAP Q-Probe
The College of American Pathologists “CAP” worked on Delta Check Q-Probes study
and published their results on April 2017. The goal of this Q-Probes research study is
for making adjustments such as:
a. Adding or removing analytes,
b. Reviewing observations to determine the maximum number of days used
in delta check calculations.

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Study conditions
1. A total of 49 facilities participated in this study.
2. Among 4505 testing episodes involving 6541 delta check alerts.
Testing episode: action of collecting samples and perform several tests on them.
3. The median frequencies of actions taken among 49 laboratories were:
Action Taken Percentage %
Clinical review 38.0
Retest of the current sample 25.0
Recheck of the current sample 20.2
Nothing 15.4
Analytical check 5.0
Other 2
Retest or check previous specimen 0

4. Time interval is the specimen collection time difference between the current and
previous results. Time interval is flexible. Most hospital laboratories choose 24 or
48 hours. Maximum time interval was 14 days.
5. Delta checks are recommended for inpatient testing. Generally, you want to select
the chemistry analytes that have the lowest biological variation.
Observations
1. Among the 240 delta check testing problems identified, the most common were
interference due to hemolysis, lipemia, or icterus, with IV fluid contamination
which is somewhat less common. Analytical and other processing or handling
errors represented very few of the testing problems.
2. The study authors thought of delta checks as a way of picking up misidentified
specimens, but even with the large number of specimens in the study, there were
only 11 instances of misidentification. Delta check is not as good for picking up
mislabeling, which represented only 5% of testing problems and 0.3 % of all testing
episodes.
3. 94% of the testing episodes involving delta checks involved no change in test
results or suspected problems. Patient results were verified and released with no
change.
4. What the study’s authors found, when there is a delta check, some analytes are
more effective at identifying problems.
a. Analytes have the highest levels of relative performance: sodium,
potassium, calcium, magnesium, MCV, mean corpuscular hemoglobin,
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 mean corpuscular hemoglobin concentration, red blood cell distribution
width, hemoglobin or hematocrit, and platelet count.
b. Less effective are: creatinine or blood urea nitrogen, albumin, chloride,
phosphorus, white blood cell count, carbon dioxide, prothrombin time, and
international normalized ratio of prothrombin time of blood coagulation.
c. The least effective are: total protein, bilirubin (total and direct), uric acid,
aspartate aminotransferase, alkaline phosphatase, glucose, lactate
dehydrogenase, gamma-glutamyltransferase, and cholesterol.
5. Delta check could be either absolute, percentage, or rate of change. The
laboratories contributed in the study split using absolute value (52 %) and
percentage (48 %). Laboratories did report using the absolute value more often
than percentage for certain analytes, such as MCV, hemoglobin, potassium, and
chloride, whereas they were likelier to use percentage more often for platelets and
enzymes.
6. When you have a delta check, a problem could involve either the current sample
or the previous one. Nevertheless, we found that previous samples were
investigated much less often compared with the current sample. This was a striking
difference, with current specimens checked 36 times more often than previous
specimens even though 23.8 % of testing problems involved the previous
specimen.
7. There was no action taken in response to a delta check 36 % or more of the time
in facilities ranked above the 75th percentile. In 10 % of the laboratories, delta
checks were not investigated in almost 80 % or more of cases. Ideally, if you have
a delta check, you should always do something.
Recommendations
1. The study authors recommend that laboratories consider using a checklist to
better standardize investigation of the delta check.
2. Many of the significant delta checks identified specimen quality issues.
3. Investigate the previous sample as well as the current sample.

Actions taken
Table 1. Worksheet Categories for Actions, Problems, and Outcomes Used by
Participants for Collecting Information about Delta Check Alerts
 None taken (current or previous specimens)
 Repeat testing (current or previous specimens)
1. Testing repeated from primary tube

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 2. Testing repeated from original aliquot
3. Testing repeated from new aliquot
4. Performed additional (non-ordered) tests
5. Checked for ABO discrepancy
 Specimen check (current or previous specimens)
1. Check for hemolysis, lipemia, and icterus.
2. Check for clot
3. Check for primary tube mislabeling
4. Check for aliquot mislabeling
 Analytical check (current specimen)
1. Checked other results on same run
2. Checked quality control
3. Retested quality control
4. Retested specimen after recalibration
5. Retested after instrument troubleshooting
 Clinical review
1. Checked blood transfusion history
2. Reviewed medical record
3. Contacted clinical personnel for more information
 Other actions
1. Checked LIS or interface
2. Rechecked calculations
3. Checked for discrepancies with other laboratory sections
4. Reviewed with technical supervisor
5. Reviewed with pathologist/laboratory director
6. Request new specimen
7. Checked for other pre-analytical problem(s)
8. Checked for other analytical problem(s)
9. Checked for other post-analytical problem(s)
 Test problem(s) suspected or confirmed (current or previous specimens) Problem
1. Analytical measurement error
2. Calculation error
3. Clotted specimen
4. Data entry error
5. Clerical error, other than data entry
6. Interface/data transmission error
7. Delay in processing
8. Delay in transport
9. Hemolysis, lipemia, icterus
10. Improper handling (temperature, light)

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 11. Improper processing (dilution, aliquot)
12. Mislabeled aliquot
13. Mislabeled specimen
14. Specimen contamination (e.g., IV fluid)
15. Wrong specimen container
16. Other problem (describe below)
 No problem identified
1. Cause for delta check is unexplained
2. Delta check caused by physiologic condition
3. Delta check caused blood transfusion
4. No testing problem, other cause not listed for delta check

Findings
Thirty analytes (30) were included in the study:
1. Chemistry: 20
2. CBC: 7
3. Coagulation: 3
Analytes Absolute Change Percentage
Change %
Chemistry
Sodium 9 mEq/L 5
Calcium 2 mg/dL 15
Potassium 1 mEq/L 20
Creatinine 1 mg/dL 30
BUN 20 mg/dL 50
Albumin 1 g/dL 20
Protein 2 g/dL 20
Total bilirubin 2 mg/dL 40
Chloride 10 mEq/L 12
Phosphorus 2 mg/dL 50
CO2 8 mEq/L 20
Magnesium 1 mg/dL 25
Uric acid 2 mg/dL 40
Direct bilirubin 2 mg/dL 80
AST --- 75
Alkaline phosphatase 20 U/L 50
Glucose 100 mg/dL 50
Lactate dehydrogenase 65
c-Glutamyltransferase --- 75
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 Cholesterol 70 mg/dL 30
Hematology
MCV 4 fL 6
Hemoglobin 2 g/dL 20
Platelet count 50 000/lL 34
WBC count 5 000/lL 35
Hematocrit 6% 14
MCH 4 pg ---
MCHC 2 g/L ---
Coagulation
Prothrombin time --- 30
INR 1 28
Fibrinogen --- 75

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Page 8 of 12
UAMS: University of Arkansas for Medical Science
Several medical facilities worked on Delta Check study individually and published the
results. Here is one example from University of Arkansas for Medical Science “UAMS”
Findings
Chemistry (serum)

Analyte Delta Check

Albumin 2.0 g/dl

Bilirubin 2.0 mg/dl

*BUN 25 mg/dl

Calcium (Ca) 3.0 mg/dl

Carbon Dioxide 15 mEq/L

Chloride (Cl) 15 mEq/L

*Creatinine 10 mg/dl

Magnesium 2.0 mEq/L

Osmolality 20 mOsm/kg

Potassium (K) 2.5 mEq/L

Sodium (Na) 15 mEq/L

Total Protein 2.0 gm/dl

**Uric Acid 2.0 mg/dl

* Non-Renal
** Non-Heme/Onc

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Keep in mind:
1. Generally studies include inpatients over 18 years old.
2. Delta check limits may change with patient age:
a. MCV elevations in neonates.
b. Creatinine decreases with age, urea increases.
3. Different rules may be needed for different population. Ex. oncology, transplant.
4. These conditions should be considered in investigation checklist when Delta
Check alarm set off.

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How to Calculate Delta Check Limits?
Setting the alerting limits of Delta Check through calculating RCV
Reference Change Value (RCV):
RCV = 2 0.5 * Z * (CVA 2 + CVI 2) 0.5
Z = For 2 tailed analyses:
 1.96 at 95% probability (“significant”);
 2.58 at 99% probability (“highly significant”)
CV A = analytical variation (from QC) = SD/Mean * 100
CVI = intra-individual variation (from literature or
http://www.westgard.com/biodatabase1.htm)

Example
Alkaline phosphatase internal QC has an SD of 0.56 U/L at a mean of 40 U/L.
CV A = 0.56 / 40 * 100 = 1.4%
Within subject biological variation (CVI ) is 6.4%
Formula is: RCV =2 0.5 * Z * (CV A 2 + CVI 2) 0.5
RCV at 95% = 1.414 * 1.96 * (1.42 + 6.42) 0.5 = 18%
RCV at 99% = 1.414 * 2.58 * (1.42 + 6.42) 0.5 = 24%

Absolute value = Mean * RCV

= 40 * 24% = 9.6 U/L

This concludes the delta check calculation guide.

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References
http://www.captodayonline.com/delta-checks-safety-net-used-useful/
http://www.archivesofpathology.org/doi/pdf/10.5858/arpa.2016-0161-
CP?code=coap-site
http://www.uams.edu/clinlab/delta.htm
http://www.arup.utah.edu/media/deltaChecks/Straseski%20DeltaCheck.pdf
https://www.westgard.com/biodatabase1.htm
http://www.qcnet.com/Portals/49/PDFs/Biological%20Variation,%20a%20practical%2
0review,%20Dr%20C.%20Ricos.pdf

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