LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 355.05 Rapid PCR SARS-CoV-2 Point of Care Test
 
Policy Category:  Clinical
Distribution Level:  Directly Operated
Responsible Party:  Pharmacy and Therapeutics
 
Approved by Curley L. Bonds II, MD, Chief Medical Officer, on Nov 17, 2023
 
I.  PURPOSE
 
This policy establishes the use of Rapid PCR SARS-CoV-2 test in the Los Angeles County Department of Mental Health (DMH/Department) directly operated clinics.
 
II.  DEFINITIONS
 
Authorized Personnel: Physicians, Nurse Practitioners, Registered Nurses, LVNs, Psychiatric Technicians, and Clinical Pharmacists

Clinic: Any DMH directly operated programs

SARS-CoV-2 test: A molecular in vitro diagnostic test utilizing polymerase chain reaction (PCR) and lateral flow technology for the qualitative, visual detection of nucleic acid from SARS-CoV-2 in clinician-collected nasal or nasal mid-turbinate swab specimens or clinician-instructed self-collected (collected on site) nasal swab specimens, collected from an individual suspected of COVID-19 by healthcare providers.

 
III.  POLICY
 
SARS-CoV-2 PCR shall be used for presumptive diagnoses of SARS-CoV-2 positive in the client population seen in directly operated programs.

Only authorized personnel shall perform the test.

Clinical competency shall be demonstrated to and deemed satisfactory by the Chief of Nursing or designee on annual basis.
 
Authorized personnel shall check the expiration date of a test kit before use.
 
Opened, used, or expired test kits shall be discarded promptly.

Authorized personnel who perform and interpret test results shall document results in the Integrated Behavioral Health Information system (IBHIS).

Test kits shall be stored at room temperature between 15°C to 30°C, 59°F to 86°F.

Test kit handling:
  1. Do not reuse kit contents: collection swabs, test cassettes, transfer pipettes, control swab, or SARS-CoV-2 buffer
  2. Do not remove the test cassette from foil pouch until immediately before use (within 30 minutes)
  3. Specimen swab must be eluted in Accula™ SARS-CoV-2 buffer immediately after sample collection
  4. Clean Accula™ or Silaris™ DOCK after each use
 
IV.  PROCEDURES
 
V.  AUTHORITIES
 
VI.  ATTACHMENT