3 Colo. Code Regs. § 709-1.15
Current through Register Vol. 47, No. 22, November 25, 2024
Section 3 CCR 709-1.15 - Pediatric Case Management and Protective StabilizationThis Rule is promulgated pursuant to sections 12-20-204, 12-220-105(3), and 12-220-106, C.R.S.
The purpose of this Rule is to recognize that all infants, children, adolescents, and individuals with special health care needs are entitled to receive oral health care that meets the treatment and ethical standard of care. These groups of individuals may need special case management in order to receive timely diagnosis and treatment, as well as to ensure the safety of the patient, practitioner, and staff. The use of protective stabilization (formerly referred to as physical restraint and medical immobilization) is an advanced behavior guidance technique which must be integrated into an overall behavior guidance approach that is individualized for each patient in the context of promoting a positive dental attitude for the patient, while ensuring patient safety and quality care. This necessitates that the dentist establishes communication with the dental staff, the patient, and the parent or guardian. It is important that the dentist and dental team promote a positive attitude towards oral and dental health in order to alleviate fear and anxiety and to deliver quality dental care.
A. Pediatric Case Management 1. Parents or legal guardians cannot be denied access to the patient during treatment in the dental office unless the health and safety of the patient, parent or guardian, or dental staff would be at risk. The parent(s) or guardian(s) shall be informed of the reason they are denied access to the patient and both the incident of the denial and the reason for the denial shall be documented in the patient's dental record.2. This provision shall not apply to dental care delivered in an accredited hospital or acute care facility.B. Training- prior to utilizing protective stabilization, the dentist shall successfully complete training beyond basic dental education through either: 1. A residency or graduate program that contains content and experiences in advanced behavior management; or2. A continuing education course of no less than six hours in advanced behavior management that involves both didactic and demonstration components.C. Methods, Indications, and Considerations for Protective Stabilization1. Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, torso, or head freely is considered protective stabilization. a. Active stabilization involves restraint by another person, such as a parent/guardian, dentist, or dental staff. This may include hand holding, head guarding, and therapeutic holding.b. Passive stabilization utilizes a restraining device.2. The use of protective stabilization must not cause serious or permanent injury and it must involve the least possible discomfort to the patient.3. Protective stabilization may be performed (with or without a stabilization device) by the: b. Parent or legal guardian.4. Dental therapists, dental hygienists and dental assistants shall not use protective stabilization by themselves, but may assist the dentist as necessary.5. Protective stabilization during diagnostic and/or dental treatment may be utilized when the following indications are present:a. A patient requires immediate diagnosis and/or urgent limited treatment and cannot cooperate due to emotional and cognitive developmental levels, lack of maturity, medical and physical conditions, or some combination thereof.b. Emergent care is needed and uncontrolled movements risk the safety of the patient, staff, dentist, or parent/guardian.c. A previously cooperative patient quickly becomes uncooperative during the appointment and protective stabilization is necessary to protect the patient's safety and to help expedite the completion of treatment already initiated.d. A sedated patient becomes uncooperative during treatment.e. A patient with special health care needs experiences uncontrolled movements that significantly interfere with the quality of care.6. Protective stabilization shall not be utilized when the following contraindications are present: a. A cooperative non-sedated patient.b. A patient who cannot be stabilized safely due to associated medical, psychological, or physical conditions.c. A patient with a history of physical or psychological trauma due to restraints (unless there are no alternatives).d. A patient with non-emergent treatment needs in order to accomplish full mouth or multiple quadrant dental rehabilitation.7. The dentist must consider the following when determining whether to recommend the use of protective stabilization techniques:a. Patient's oral health needs.b. Effect on quality of dental care.c. Emotional and cognitive development levels as it relates to the patient's ability to understand and cooperate during dental treatment.d. Medical and physical conditions.e. Parental/guardian preferences.f. Utilizing alternative, less restrictive, behavior guidance methods.D. Prior to Utilizing Protective Stabilization1. Obtain informed consent- protective stabilization, with or without a restrictive device, performed by the dentist requires informed consent from the parent or legal guardian; except when a sedated patient becomes uncooperative during treatment. a. Benefits and risks of protective stabilization, as well as alternative behavior guidance techniques, i.e. deferring treatment, or utilizing sedation or general anesthesia must be explained to the parent or guardian.b. A detailed written consent identifying the specific technique of protective stabilization must be obtained separately from the consent for other procedures as it increases the parent's or guardian's awareness of the procedure. The consent must also identify the reason why protective stabilization is required.2. Obtain an accurate, comprehensive, and up-to-date medical history. This should include: a. Conditions that may compromise respiratory function, e.g. asthma.b. Neuromuscular or bone/skeletal disorders that may require additional positioning aids.c. Previous trauma from having movement restricted.E. Documentation- the following must be included in the patient's record:1. Indication for stabilization.2. Type of stabilization utilized and by whom, including parent or guardian.3. Signed informed consent for protective stabilization.4. Reason for parental/guardian exclusion during protective stabilization, if applicable.5. Duration of application of stabilization (start time and end time).6. Status of airway, peripheral circulation, and proper positioning of stabilization device/method at least every 15 minutes throughout duration of stabilization.7. Behavior evaluation/rating during stabilization.8. Any unexpected outcomes, such as skin markings.9. Whether the parent/guardian, if not present in the room, was given progress updates at least once per hour. Verbal consent for continued stabilization must be obtained at least once per hour and documented in the dental record.10. If the protective stabilization technique changes during the procedure from that presented to the parent or legal guardian in the initial informed consent discussion, the parent or legal guardian shall be notified, consulted immediately, and verbal consent documented for continued treatment.11. Management implications of future appointments. Amended October 24, 2007, Effective December 31, 2007; Amended January 21, 2010, Effective March 30, 2010; Re-numbered December 30, 2011; Amended April 28, 2016, Effective June 30, 2016; Amended November 5, 2020; Effective December 30, 2020; Amended November 3, 2022; Effective December 30, 202238 CR 04, February 25, 2015, effective 3/30/201538 CR 11, June 10, 2015, effective 6/30/201539 CR 04, February 25, 2016, effective 3/16/201639 CR 10, May 25, 2016, effective 6/30/201639 CR 16, August 25, 2016, effective 9/14/201641 CR 04, February 25, 2018, effective 3/17/201841 CR 11, June 10, 2018, effective 7/3/201841 CR 14, July 25, 2018, effective 8/14/201842 CR 11, June 10, 2019, effective 6/30/201942 CR 23, December 10, 2019, effective 1/1/202044 CR 11, June 10, 2021, effective 6/30/202144 CR 16, August 25, 2021, effective 9/14/202144 CR 23, December 10, 2021, effective 12/30/202145 CR 21, November 10, 2022, effective 10/4/202245 CR 23, December 10, 2022, effective 12/10/202245 CR 23, December 10, 2022, effective 12/30/2022