LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 355.04 Point-of-Care Blood Glucose Testing (306.03)
 
Policy Category:  Clinical
Distribution Level:  Directly Operated
Responsible Party:  Pharmacy and Therapeutics Committee
 
Approved by Curley L. Bonds, MD, Chief Medical Officer on Jul 19, 2023
 
I.  PURPOSE
 
This policy establishes the use of a Clinical Laboratory Improvement Amendments-waived (CLIA-waived) blood glucose test that uses capillary whole blood from a finger stick to determine clients' blood glucose at Los Angeles County Department of Mental Health (DMH/Department) directly operated clinics. The test serves as a monitoring tool for clients whose conditions or treatment require blood glucose monitoring.

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II.  DEFINITIONS
 
Clinic: Any DMH directly operated facility and DMH staff-operated field-based program.

Point-of-Care Blood Glucose Test: CLIA-waived in vitro diagnostic test used to determine quantitative blood glucose using capillary whole blood from a finger stick.

Authorized personnel: physicians, registered nurses, licensed vocational nurses, nurse practitioners, psychiatric technicians or clinical pharmacists who have completed training and demonstrated competency to perform point-of-care blood glucose tests.
 
III.  POLICY
 
Point-of-care blood glucose monitor, lancets, and test strips shall only be obtained from DMH Pharmacy Services.

Point-of-Care Blood Glucose Tests shall only be used for clients who:
  • Present with dizziness or lightheadedness and are known to have diabetes or hypoglycemic symptoms;
  • Are known to have diabetes and report abnormal blood glucose less than 70 mg/dL or greater than 300 mg/dL; or
  • Require routine monitoring of blood glucose because they are at risk or have been diagnosed with diabetes.
Only Authorized Personnel who have passed competency shall perform blood glucose tests.

Nova Max Glucose Test Strips shall be stored in a cool dry place between 15°C to 30°C (59°F to 86°F) in a tightly closed vial away from direct sunlight, moisture, and heat. Test strips shall not be refrigerated or frozen.

Use only Nova Max Glucose Test Strips for testing with Nova Max Glucometer.

Nova Max Plus Blood Glucose Monitor shall be stored between -25°C to 46°C (-13°F to 115°F). Operational temperature shall be between 14°C to 40°C (57°F to 104°F). The relative humidity range shall be between 10% to 90% non-condensing.

The maximum altitude for the blood glucose monitor operation is up to 15,000 feet (4500 meters).

Authorized personnel shall only remove the test strip from the vial immediately prior to performing the test.

The discard date of each test strip vial shall be six (6) months after the open date.
  • Authorized personnel shall write the discard date on each test strip vial;
  • Authorized personnel shall check the discard date of the test strip prior to use; and
  • If the expiration date of the test strip comes before six (6) months of vial opening, the expiration date shall be used as the discard date.
Test strips from vials opened for more than six (6) months or expired test strips shall not be used.

Used test strips shall be discarded properly.

Test strips shall not be tampered with in any way.

Only use Nova Max Control Solution for quality control check to ensure blood glucose monitor and test strips are working properly.
  • Check control solution expiration date prior to testing.
  • Store control solutions at room temperature below 30°C (86°F) only for three (3) months after opening and discard after three (3) months.
Authorized personnel shall perform control solution test under the following circumstances:
  • Before using a blood glucose monitor for the first time;
  • At least once a week thereafter;
  • Each time a new vial of Nova Max Glucose Test Strip is opened;
  • If the test strip vial cap is left open for any length of time;
  • If the blood glucose monitor is dropped; and
  • When blood glucose test results are not consistent with clinical presentation.
Blood glucose monitor and test strips shall not be stored in the car or in a refrigerator.

The exterior of the blood glucose monitor shall be cleaned after each client only with 70% isopropyl alcohol or approved disinfecting wipes:
  • Keep liquids from entering the test strip port or the Left, Right, and Mode buttons;
  • DO NOT immerse blood glucose monitor or hold the monitor under running water; and
  • DO NOT spray the monitor with a disinfectant solution.
Authorized personnel who perform and interpret test results shall also document results in the Integrated Behavioral Health Information System (IBHIS).
 
IV.  PROCEDURES
 
Procedures - Point-of-Care Blood Glucose Testing
 
V.  AUTHORITIES
 
VI.  ATTACHMENT
 
Package Insert Nova Max Blood Glucose Monitor Owner's Guide