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

Helium Tank/ ABHR Dispenser Location

Q: Can we have a helium tank if secured properly in gift shop? And what are requirements for hand sanitizer locations- location to switches or outlets?

A: Provided the tank is secured properly, and there is less than 300 cubic feet of compressed gas total in the Gift Shop, you may have a helium tank in the shop. The typical ‘H’ tank (which is approximately 9 inches in diameter and about 55 inches tall) contains 250 cubic feet, so 1 ‘H’ tank properly secured in the gift shop would be permissible (but only one tank). Joint Commission has changed their requirements to allow the Alcohol Based Hand Rub (ABHR) dispensers to be mounted no less than 1 inch side-to-side to an electrical outlet or an electrical switch. However, CMS is still on the definition of no less than 6 inches center-to-center between an ABHR dispenser and an electrical outlet or switch. Once the new 2012 edition of the Life Safety Code is adopted, then CMS will be on the same page as Joint Commission

Alcohol Based Hand Rub Dispenser Spacing

Q: What is the actual spacing requirement for alcohol based hand-rub (ABHR) dispensers from electrical sources such as light switches in the hospital? I have heard it must be 4 feet from the switch, then I heard it is 6 inches from the switch, then someone says it is 1 inch. What is the actual requirement now?

A: This really depends on which authority having jurisdiction (AHJ) is evaluating the ABHR dispensers. NFPA allowed ABHR dispensers for hospitals in Tentative Interim Amendment (TIA) #787, issued in April, 2004, and made it retroactive to the 2003 and the 2000 editions of the Life Safety Code (LSC). This TIA allowed ABHR dispensers to be mounted in corridors in hospitals, and they listed multiple requirements that the hospital must follow. One of the requirements involved the distance between the dispenser and potential ignition sources, such as light switches. This is what the TIA stated: “The dispensers shall not be installed over or directly adjacent to an ignition source.” Originally, there was no specific distance listed that the dispenser must be from an ignition source, other than it cannot be adjacent to it. So, many accrediting agencies came up with their own interpretation and one of the better known interpretations was made by the Joint Commission which required 6 inches from centerline of the ABHR dispenser to the centerline (or edge, depending on which surveyor you got) of the ignition source. Since then, NFPA has stated in subsequent editions of the LSC that ABHR dispensers must be separated from ignition sources by one inch, side to side. But, we are still on the 2000 edition and this one inch rule does not apply to the 2000 edition. However, George Mills, the Director of Engineering at the Joint Commission recently stated that they will accept the one inch side to side definition, rather than the older 6 inch centerline to centerline interpretation they previously made. So, if you are Joint Commission accredited, then you are good if you follow the one inch rule. However, for all other AHJs, it is whatever they say it is. I suggest you contact your state and local AHJs to find out how they interpret the word ‘adjacent’.

Positioning of the ABHR Dispensers from Ignition Sources

The current Life Safety Code (LSC) edition (the 2000 edition) that healthcare facilities must comply with, was issued a Tentative Interim Amendment (TIA) by the NFPA in April, 2004, that allows Alcohol Based Hand-Rub (ABHR) dispensers in exit access corridors. Along with this TIA came a list of restrictions and qualifications concerning the ABHR, and the distance between the ABHR dispenser and ignition sources was describe as as follows:

“The dispenser shall not be installed over or directly adjacent to an ignition source.”

Many authorities having jurisdiction (AHJ) struggled with what “adjacent to an ignition source” actually meant. The Joint Commission set the pace on this interpretation and required 6 inches from center-line from the dispenser, to the center-line (or edge, depending which surveyor you have) of the ignition source. This was the standard that The Joint Commission used to evaluate compliance with ABHR dispensers and their proximity with ignition sources.

Then came the 2009 edition of the LSC which made a change in how the ABHR dispensers are to be mounted in regards to ignition sources. The new requirement [18/19.3.2.6 (7)] said:

“Dispensers shall not be installed in the following locations:

a). Above an ignition source for a horizontal distance of 1 inch to each side of the ignition source

b). To the side of the ignition source within 1 inch horizontal distance from the ignition source

c). Beneath an ignition source within within 1 inch vertical distance from the ignition source”

 So, that means the 2009 edition of the LSC allows ABHR dispensers to be mounted to the side of an electrical switch, outlet or other such ignition source as long as there is at least 1 inch clearance between the two items. But, we are still on the 2000 edition of the LSC, right? Well, yes we are, but that doesn’t mean that AHJs can’t make exceptions to their interpretations and allow compliance with a different code or standard.

Last August, the Senior Engineer for the Joint Commission Standards Interpretation Group, Mr. George Mills, announced at an ASHE regional conference, that his organization will now reference the 2009 edition of the LSC [18/19.3.2.6 (7)] in regards to enforcing the 1 inch distance between the ABHR dispensers and the ignition source, effective August 15, 2011. This is good news and another indication that accrediting organizations are making attempts to make LSC interpretations easier for the hospital facility managers.

 So, that means the ABHR dispenser in the picture to the left would be permitted (provided it meets the 1 inch rule), according to the new interpretation from The Joint Commission.

You still need meet other restrictions in the TIA, which are:

-ABHR dispensers are only permitted in corridors at least 6 feet wide

  • -The maximum capacity of a ABHR dispenser is 1.2 liters in corridors, rooms and areas open to the corridor; and 2.0 liters in suites of rooms
  • -ABHR dispensers must be mounted no less than 4 feet from each other, measured horizontally

-No more than 10 gallons total aggregate quantity of ABHR solution in dispensers per smoke compartment, and no more than 5 gallons total allowed to be stored outside of a fire rated cabinet

-Dispensers are not allowed to be mounted directly adjacent to or above ignition sources [Editor’s Note: This has since been interpreted to require 1 inch clearance side to side.]

-When dispensers are installed over carpeted areas, the entire smoke compartment is required to be protected with sprinklers

ABHR Dispensers in Carpeted Areas

Q: During a recent survey, the surveyor told us that we could not have Alcohol Based Hand Rub (ABHR) dispensers over carpeting in areas of the hospital that do not have sprinklers? I thought the LSC was altered to allow ABHR dispensers in corridors. What is the truth?

A: Yes, the surveyor was correct: ABHR dispensers are not permitted in locations with carpeted floor coverings unless the entire smoke compartment is protected with automatic sprinklers. This applies to corridors as well as rooms. The Tentative Interim Amendment (TIA) number 787 issued by the NFPA in April, 2004 applies to both the 2003 and 2000 editions of the LSC, which effectively alters the code to allow the ABHR dispensers. However, there are limitations:

  1. When installed in corridors, the corridor must be at least 6 feet wide.
  2. The maximum capacity of the dispensers is 1.2 liters in rooms and corridors, and 2.0 liters for suites.
  3. The dispensers must be horizontally spaced at least 4 feet from each other.
  4. Not more than an aggregate total of 10 gallons is allowed in use outside of a storage cabinet per smoke compartment.
  5. Storage quantities of 5 gallons or more must meet NFPA 30 standards (fire-rated cabinets).
  6. Dispensers cannot be installed over or adjacent to an ignition source.
  7. Dispensers cannot be installed over carpeted floor coverings in non-sprinklered smoke compartments.
  8. Corridor projection up to 6 inches is allowed in corridors wider than 6 feet to accommodate the dispensers.

The July, 2011 issue of HLSC explains how ABHR dispensers are not permitted in corridors of business occupancies. Also, the current interpretation used by many AHJs for item #6 above, is 1 inch clearance between the edge of the ABHR dispenser and the edge of the ignition source. For a complete transcript of this TIA, log-on to the NFPA website at www.nfpa.org, and type in “TIA 787” in the search box, and click on “SC #04-4-17”. By the way, the American Society of Healthcare Engineers (ASHE) was largely responsible for getting NFPA to issue this TIA, so support your local ASHE chapter and join the ASHE national society. They are a great resource in educational and advocacy opportunities for the local hospital facilities manager.

ABHR Dispensers in Business Occupancies

Q: Brad- Are alcohol based hand-rub (ABHR) dispensers permitted in corridor of business occupancies?

A: The LSC is very silent about alcohol based hand rub (ABHR) dispensers in a business occupancy corridor. The Tentative Interim Amendment issued in April, 2004 which modifies the 2000 edition of the LSC, permits ABHR dispensers in corridors of healthcare occupancies with many exceptions and requirements. Subsequent editions of the LSC do allow them in ambulatory care occupancies, but does not address business occupancies. Section 8.4.3.2 of the LSC 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…” The ABHR dispensers are 60% – 70% alcohol, which makes them flammable liquids and therefore would not be allowed in corridors unless the occupancy chapter specifically allows them. So, in summary, based on what NFPA has said and what is written in the LSC, I would say no, they are not permitted in business occupancies. But, as always, it really doesn’t matter what I say, all that matters is what the AHJ says. So, I suggest you contact your local and state AHJs and ask them if it is permitted. That may sound like a cop-out, but they really are the authorities and when something is not clear in the code book, they are the ones to make the interpretation.

Distance Between Mounted ABHR Dispensers

Q: Is there a rule about how far apart hand sanitizers should be? One of my directors wants to put one just inside a patient room and outside in the corridor as well.

A: Yes, there is. In April of 2004, the NFPA passed Tentative Interim Amendment (TIA) 787 that applies to the 2000 and the 2003 editions of the LSC, which effectively modifies these two editions to allow alcohol based hand-rub (ABHR) dispensers in corridors of healthcare occupancies. In this TIA are many requirements that need to be met in order to mount the ABHR dispensers in corridors, including limiting the aggregate total of ABHR product in dispensers to 10 gallons in any one smoke compartment. The TIA says the dispensers shall have a minimum horizontal spacing of 4 feet from each other. This horizontal spacing is not limited to just corridors, so I would say if you measured the horizontal distance between the two dispensers going through the open door, and if the measurement is less than 4 feet, then you would probably be considered out of compliance.

Alcohol Based Hand-Rub Dispensers

Q: I know that Joint Commission permits alcohol based hand-rub (ABHR) dispensers in the corridors of hospitals, but I do not see where it is permitted according to the Life Safety Code. I have a VP who doesn’t think it is allowed and I would like to show him where it is permitted.

A: Actually, alcohol based hand-rub dispensers were not addressed when the 2000 edition of the Life Safety Code was approved, but that does not mean it is not permitted. In 2004 the NFPA issued a Tentative Interim Agreement (TIA) that permits the use of ABHR dispensers, under certain limitations. This TIA is retroactive to the 2000 and 2003 editions of the NFPA 101 Life Safety Code, and the text of the TIA is included as part of the 2006 and 2009 editions. As a reminder, here is a summary of the limitations explained in the TIA:

  • Corridors must be at least 6 feet wide
  • The maximum capacity of each dispenser is 1.2 liters, or 2.0 liters in suites of rooms
  • Dispensers must be separated from each other by 48 inches
  • Not more than an aggregate of 10 gallons of ABHR solution are allowed to be used in a smoke compartment
  • Not more than 5 gallons of ABHR solution may be stored in a smoke compartment without meeting the storage requirements of NFPA 30 Flammable and Combustible Liquids Code
  • ABHR dispensers cannot be installed over or adjacent to ignition sources
  • When installed directly over carpeted floors, ABHR dispensers can only be installed if the smoke compartments
  • A maximum of 6 inch protrusion into the corridor is permitted above the handrail height, for the ABHR dispensers

The 2009 edition of the LSC permits aerosol containers as dispensers with a maximum individual capacity of 18 oz, and a maximum aggregate 1135 oz outside of a fire rated storage container, per smoke compartment. However, this is not part of the TIA issued in 2004, and is not part of the 2006 edition. You may download a free copy of the 2004 TIA from the NFPA website at no charge.