ABHR Dispensers

Q: Are alcohol-based hand rub (ABHR) dispensers allowed in Operating Rooms or Operating Room suites. We could not find a prohibition of them in LSC — just double checking.

A: The Life Safety Code does not prohibit ABHR dispensers in operating rooms or operating room suites.

Please check with state and local authorities to determine if they have any restrictions on ABHR dispenser locations.

ABHR Dispensers

Q: We currently have ABHR installed on the outside of our patient bays and would like to install an additional dispenser in the patient bay itself (at the point of use). If an ABHR container is installed on the wall on the outside of the patient bay next to the door, can a dispenser be installed on the other side of the wall on the inside of the bay next to the door (they would mirror each other; one interior and one exterior). I did measure the distance between the two from interior to exterior and it is only 1 ft. wrapped around. What is the interpretation of the 4-foot dispenser separation requirement? Just want to make sure we are in compliance with LSCs!

A: The interpretation I received is the ABHR dispensers need to be separated by 4 feet (horizontally), including a wrap-around a door frame. So, what you described (ABHR dispensers separated by only 1-foot, but on separated sides of the wall) would not be permitted.

ABHR Dispensers

Q: Could you clarify the placement of alcohol based hand dispensers in corridors and waiting rooms.  I was just looking for clarification.

A: For healthcare occupancies (i.e. hospitals, nursing homes, long-term care, free-standing ERs) follow section 19.3.2.6 of the 2012 Life Safety Code for alcohol based hand-rub (ABHR) dispensers, which basically says:

  • You cannot mount them in corridors less than 6 feet wide
  • Maximum dispenser capacity is 1.2 L for rooms and corridors and 2.0 L for suites
  • Maximum dispenser capacity for aerosol containers is 18 oz.
  • Dispensers must be separated from each other by 48 inches
  • Not more than 10-gallon aggregate total of ABHR solution or 1135 oz. of aerosol solution shall be in use outside of a storage cabinet per smoke compartment, except for the next bullet point
  • One dispenser per room shall not be included in the aggregate quantities mentioned above
  • Storage of quantities greater than 5 gallons in a single smoke compartment must meet the requirements of NFPA 30 (1-hour FRR room, or fire-resistant cabinet)
  • Dispensers must be mounted at least 1 inch away (as measured side-to-side) from ignition sources, and cannot be mounted above ignition sources
  • Dispensers mounted over carpeted floors are permitted only in sprinklered smoke compartments
  • Maximum 95% alcohol by content
  • The dispenser must be designed, constructed and operated in such a way that ensures accidental or malicious activation of the dispensing device is minimized

For ambulatory health care occupancies (ASCs, outpatient physical therapy) you follow section 21.3.2.6 which is essentially the same as 19.3.2.6. For business occupancies (physician’s offices, administration facilities) there is nothing in the occupancy chapter that permits ABHR dispensers in corridors, but other than corridors, you would follow the same as above.

Alcohol Based Hand-Rub Solution Storage

Q: Our hospital bulk stores alcohol based hand-rub (ABHR) sanitizer containers of 1000 ML (33.8 fl. oz.) per container & 750 ML (25 fl. oz.) per container in its housekeeping department for future placement on the units. The 1000 ML containers have 62% ethyl alcohol, which the 750 ML containers have 70% ethyl alcohol. The 1000 ML containers come 8 to a box and we have 25 boxes on pallets, while the 750 ML containers come 6 to a box and we can have up to 180 boxes on pallets at one time in the warehouse/storeroom, which is quite large and is open to the deck above. This room is located in the basement of a high rise that has an ED on the floor above, ORs on the 2nd floor and inpatient sleeping floors above that. The room and whole building have both smoke detectors and sprinklers and was constructed in 2011. Half of the room where the sanitizer is bulk stored is surrounded by a 2-hour fire/smoke barrier, while the other half has 1-hour fire resistive construction. My questions are this: Is the storage of this much ABHR sanitizer acceptable? If not, what would be required? We do have a room off this one that is totally surrounded by a 2-hour fire/smoke barrier. If the room in question is not acceptable, would this room be okay?

A: The storage of what you described is over 33,000 fluid ounces which is more than 263 gallons of flammable Class IC liquids. Hand sanitizer solution is considered a Class IC flammable liquid according to NFPA 30-2012, Flammable and Combustible Liquids Code. This is also based on the Safety Data Sheets of most brand-name hand sanitizers which state the flash point is 73 degrees F, and some of them have a boiling point of 176 degrees F. According to NFPA 30, this makes it a Class IC flammable liquid.

According to NFPA 30, you are permitted to store 263 gallons in one location (actually, you can store up to 2750 gallons of Class IC flammable liquids in one location, but there are limitations:

  • The maximum height of the pile (i.e. pallets) is 5 feet
  • The storage of the liquids cannot obstruct access to egress in the room. A fire in the liquid storage cannot prevent egress from the room.
  • Storage cannot be in a basement
  • An inside storage room with a total floor area less than 150 square feet is required to be protected with fire-resistant construction of 1-hour (walls, ceiling floors)
  • An inside storage room with a total floor area more than 150 square feet but less than 500 square feet is required to be protected with fire-resistant construction of 2-hours (walls, ceiling floors)
  • Inside storage rooms with a total floor area 500 square feet or more are not permitted.
  • Containment or drainage protection is required.

So…based on your comments I would say you need to move the stored items out of the basement and into a room that is less than 150 square feet and is 1-hour fire rated protected, and you need to provide containment or drainage protection.

To be honest… most hospitals that I visit do not store this much of the hand sanitizer liquids in their facility. They store much less, and keep them in flammable cabinets which would not require 1-hour fire rated rooms. I know why your people want so much as it comes cheaper in bulk…. But the cost to properly store this stuff far outweighs the savings of buying in bulk.

ABHR Dispensers in Business Occupancies

Q: For business occupancies, does the requirement that alcohol based hand sanitizers cannot be installed above a carpeted floor apply? The business occupancy does not have an automatic fire suppression system.

A: Please be aware that alcohol based hand-rub (ABHR) dispensers are not permitted in the egress corridors of Business Occupancies. This is found in section 38/39.3.2.1 of the 2012 LSC which references section 8.7 of the same code. Section 8.7.3.2 states: “No storage or handling of flammable liquids or gases shall be permitted in any location where such storage would jeopardize egress from the structure…” Since corridors are used as paths of egress in business occupancies that means ABHR dispensers are not permitted in business occupancy corridors.

Now, sections 18/19/20/21.3.2.6 of the 2012 LSC allows ABHR dispensers in corridors of healthcare occupancies and in ambulatory health care occupancies…. but not business occupancies. These sections do allow ABHR dispensers that are mounted over carpeted floors, provided they are located in fully sprinklered smoke compartments. The 2012 Life Safety Code does not restrict ABHR dispensers in offices, exam rooms, and other rooms that are separated from the corridor in business occupancies.

So, to answer your question, the entire story where the ABHR dispenser is located over a carpeted floor must be protected with sprinklers. If you do not have sprinklers, then the ABHR dispensers would not be permitted in areas with carpeted floors. The NFPA standards do not have any exceptions for ABHR dispensers that have ‘drip trays’ built into them.

Storage of ABHR Solution

Q: I am looking for clarification on the storage of alcohol based hand rub (ABHR) solution. I know the standard indicates that no more than 10 gallons of ABHR can be stored in a single smoke compartment. However, my question is how much can be stored in a room designated as a hazardous area? We were recently cited for having 11 gallons (total) of ABHR stored in an area that we have identified as a hazardous area. It is sprinkled; has a 2-hour rated door, and this storage area is within our purchasing area which is also behind a 2-hour rated smoke compartment door. Any clarification you could provide would be helpful. Is there something additional we need to have in place to store this Class 1B flammable liquid in the hazardous area?

A: Actually… you have that backwards. Not more than 5 gallons of ABHR solution is permitted to be stored in a single smoke compartment without meeting the requirements of NFPA 30 Flammable and Combustible Liquids Code; not 10 gallons. So, if you were cited for having 11 gallons of ABHR solution stored outside of NFPA 30 requirements, then you were 6 gallons (or 120%) over the limit which is a significant amount. The 10 gallon limit is the amount of ABHR solution in dispensers (not storage) per smoke compartment.

So… what does NFPA 30 require for storage of class IB flammable liquids?

  • Section 4.2.3 says the maximum size metal or plastic container for class IB liquids is 5 gallons (this is where the maximum 5 gallons of ABHR in storage comes from);
  • Section 4-3.1 says not more than 60 gallons of class I or class II flammable liquids may be stored in a single storage cabinet;
  • Section 4-3.2 says not more than three storage cabinets are permitted in one fire area (i.e. smoke compartment);
  • Section 4-3.3 has detailed information on how storage cabinets must be constructed, and cabinets with a listing as meeting the NFPA 30 requirements are acceptable;
  • Section 4-3.4 says storage cabinets are not required to be vented, but if they are vented to they have to be vented to the outdoors;
  • Section 4-4.2.1 says interior storage rooms containing more than 5 gallons of class IB liquids (in lieu of listed storage cabinets) up to 150 square feet are required to be 1-hour fire rated, and from 150 square feet up to 500 square feet are required to be 2-hour fire rated (rooms larger than 500 square feet are not permitted to be used for storage of class IB liquids);
  • Sections 4-4.3.5 and 4-5.1.5 says class I liquids are not permitted to be stored in the basement of a facility;

Not all hazardous areas are actually 1-hour fire rated, so care must be taken when deciding to store ABHR solution in hazardous areas. You say your hazardous area is 2-hour fire rated, which seems a bit odd, since hazardous areas are not required to be more than 1-hour fire rated. But it is what it is, and you would be permitted to store ABHR solution in quantities larger than 5 gallons if the 2-hour fire rated room is not larger than 500 square feet. Also, that room would not be permitted to be in the basement.

ABHR Dispensers in Business Occupancy Corridors?

Q: Can you give me some direction in the Life Safety Code on where alcohol-based hand rub (ABHR) dispensers are not allowed in business occupancy corridors?

A: Take a look at section 39.3.2.1 of the 2012 LSC. It says hazardous areas shall be protected in accordance with section 8.7. Section 8.7.3.2 says “No storage or handling of flammable liquids or gases shall be permitted in any location where such storage would jeopardize egress from the structure unless otherwise permitted by 8.7.3.1.” Section 8.7.3.1 discusses the various methods to store flammable liquids. ABHR product is mostly alcohol which is a flammable liquid; therefore, it is not permitted in any location that would jeopardize egress (i.e. corridors).

Section 8.7.3.2 does not apply to healthcare occupancies because section 19.3.2.6 actually permits ABHR dispensers in egress corridors. Similarly, section 21.3.2.6 does as well for ambulatory health care occupancies. But, chapters 38 and 39 do not have any such language… therefore, ABHR dispensers are not permitted in egress corridors of business occupancies.

If you’re wondering, when the requirements in the core chapters (chapter 1 – 10) differ with the requirements of the occupancy chapters, the occupancy chapters govern (see section 4.4.2.3).

ABHR Dispensers

Q: In regards to the new CMS requirements regarding corridor projections, will alcohol based hand-rub (ABHR) dispensers have to comply? Currently, our ABHR dispensers exceed the 4-inch limit for items projecting into the corridor. Will there be any equivalency permitted for this requirement?

A: CMS said in their final rule to adopt the 2012 LSC (issued May 4, 2016) that they will enforce the 4 inch projection rule rather than the 6 inch rule that NFPA permits. They take this more restrictive requirement from the ADA requirements but the problem is, ADA applies to new construction and is not retroactive to existing conditions. CMS did not clarify that their 4 inch corridor projection rule is only for new construction, so it appears to me that they intend to enforce it in all situations… new and existing.

It remains unclear if the accreditation organizations will enforce this or not. They should, because if they don’t and the hospital has a validation survey and is cited by the state agency for violating the 4 inch projection rule, then that will eventually reflect poorly on the accreditation organization. But with surveyors being the humans that they are, it is unclear if they will enforce this or not. While I do not recommend it, you can take a ‘wait-and-see’ approach to determine if you get cited for it. You will eventually, because CMS will enforce it. So I suggest you take action to eliminate those dispensers and look for new ones that do not extend more than 4 inches. There is no equivalency for this issue. I would think a waiver would not be approved for such a minor issue either.

Alcohol Based Hand-Rub (ABHR) Dispensers

Q: In the 2012 edition of the Life Safety Code, section 19.3.2.6 (9) states dispensers of ABHR are permitted to be installed directly over carpeted floors in fully sprinkled smoke compartments. My question is: Does said dispenser need to have the catch pan installed under it? My second question is: If said dispenser is installed on a pedestal (also called cough stations) and has a catch type pan or area under the dispenser, is it acceptable to place the pedestal in a carpeted floor that is not sprinkled?

A: No on both accounts. There is no provision in the Life Safety Code for catch-pans as part of the ABHR dispenser for a qualification for use in a carpeted area, in a non-sprinklered smoke compartment. While it kind-of makes sense, unfortunately there is no provision that allows ABHR dispensers with catch-pans to be installed in a carpeted areas that are not protected with sprinklers.

Changes in How ABHR Dispensers Are Regulated

Q: I read an article you wrote on alcohol based hand rub (ABHR) dispensers for FacilityCare.  We have had a question come up about changes in the regulations concerning the locations of ABHR dispensers in hospitals; are there any changes to the restrictions?  Do you know anything about this?  It is an issue for us right now as we have a vendor installing and relocating over 500 dispensers in our hospital and need to be sure we understand the regulations correctly.

A: There will be changes on how ABHR dispensers will be regulated when the new 2012 LSC is finally adopted. The changes do not involve the elimination of regulations concerning ABHR dispensers, but the changes will make it a bit easier to have more of them in your corridors.

The changes involve the number of dispensers permitted within a single smoke compartment. Currently under the 2000 LSC, you are only permitted 10 gallons of the ABHR product in dispensers within any one smoke compartment. So, for a 1 liter ABHR dispenser, that means you are limited to 37 dispensers per smoke compartment (3.7 liters per gallon x 10 gallons = 37 liters). This means, if you have a smoke compartment that has 30 patient sleeping rooms, and you have one dispenser in each room, that only leaves you with 7 ABHR dispensers to be located in other areas of the smoke compartment. Not a desirable situation.

When the new 2012 LSC is finally adopted, the new rule will allow one dispenser per room (not limited to a patient sleeping room) to not be included in the total aggregate quantity of 10 gallons of ABHR product in dispensers, per smoke compartment. That means, in the same scenario listed above, those 30 ABHR dispensers in each patient sleeping room now do not count towards the aggregate total of 10 gallons of product in dispensers per smoke compartment, which leaves you with 30 more ABHR dispensers to place around the smoke compartment. A very much improved situation.

The new rule will also allow a total aggregate of 1135 oz. of aerosol ABHR product in dispensers, which equates to something like 63 – 18 oz. dispensers per smoke compartment. The new rule also allows ABHR dispensers in Ambulatory Care occupancy corridors (it didn’t before), but it does not address business occupancy corridors, which means it is not permitted.

My advice is add only the number of dispensers permitted under the current code (10 gallons in ABHR dispensers maximum per smoke compartment, including those in the rooms) and do not install the additional dispensers that will be permitted with the new code, until the new 2012 LSC is adopted