Dec 04 2017

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.


Jul 21 2017

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.


Jul 10 2017

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.


May 31 2017

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).


May 25 2017

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.


Jan 05 2017

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.


Aug 21 2015

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


Apr 27 2015

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


May 14 2012

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’.


Oct 01 2011

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.


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