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.


Nov 10 2017

Under Sink Storage

Category: Questions and Answers,Storage,Under SInkBKeyes @ 12:00 am
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Q: Is there a Life Safety Code requirement for cabinet doors to be locked underneath sinks in patient rooms, in a hospital?

A: No… There is no Life Safety Code standard or requirement whereby doors underneath sinks must be locked. However, there is an Infection Control concern that anything stored underneath a sink may become contaminated from soiled water that leaks from the sink drain. Therefore, many accreditation organizations require hospitals to either restrict clean items from being stored underneath sinks, or at least conduct a risk assessment to evaluate the risks associated with that.

As an example, The Joint Commission says in their Frequently Asked Questions that their standards do not specifically address under sink storage, but they say organizations should conduct risk assessments concerning the issue. You need to also contact your state and local authorities to determine if they have more restrictive requirements.

In my travels, I see many hospitals either lock or screw shut the doors to under sink storage. It is an easier way to prevent clean supplies from being inadvertently placed there.


Oct 16 2017

Portable Storage Racks

Category: Questions and Answers,Sprinklers,StorageBKeyes @ 12:00 am
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Q: We have a surveyor that says if we have portable storage racks against the perimeter walls and have items stored closer than 18 inches of the ceiling but the sprinkler is 4 feet away, we are in violation of the LSC. He states since the racks are not fixed to the wall, that this is the reason. Is he correct?

A: It’s not an issue of being correct; it’s an issue of interpretation. I would agree with the surveyor’s interpretation. Even though the actual standard in NFPA 13 does not explain it in this detail, the interpretation makes sense. The rack against the wall which is secured (or at least it is not mobile) stays in place and can have items stored up to the ceiling and still be compliant. However, the rack that is mobile (i.e. it has wheels) can be moved around and can obstruct the spray pattern of the sprinkler.

It makes sense to me, but remember; it doesn’t matter what I think. The surveyor represents the AHJ and it matter what he thinks. You can try to appeal the decision if you want, and you might succeed. But the interpretation actually makes sense to me.


Oct 13 2017

Storage in a Corridor

Category: Corridors,Questions and Answers,StorageBKeyes @ 12:00 am
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Q: If I had a hallway (breezeway which connects two healthcare occupancies) which is greater than 8 feet wide (approximately 12ft) and beds and other equipment (usually broken chairs) are being stored on one side of the breezeway for more than 30 minutes, would this be allowed as long as the width is maintained at 8ft or greater?

A: Yes… it would be permitted according to section 18.2.3.4 of the 2012 Life Safety Code, provided the items stored in the corridor allow for a clear width of 8 feet in the corridor, and the items stored does not constitute a hazardous area. So, combustible items such as furniture would not be permitted if the total area of the stored furniture exceeds 50 square feet. Also, flammables would not be permitted to be stored in the corridor.

Another thing to look at is if the corridor could possibly be used by inpatients. If so, then the clear width must be maintained at 8 feet. But if there is no chance of inpatients using this connector corridor, then the required width would be 44 inches.


Sep 25 2017

Storage in Non-Sprinklered Buildings

Category: Questions and Answers,StorageBKeyes @ 12:00 am
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Q: What is the storage height requirement in buildings that are not sprinkled? In other words, how high can we stack items on shelves in storage areas in a non-sprinkled building?

A: This depends on what you are stacking. Generally speaking, the Life Safety Code does not limit the height of items stored, but there may be other codes and standards that limit specific things from being stacked too high, depending on the industry of the items stacked.

But if you’re referring to a hospital, then NFPA 13 does limit items from being stored within a vertical distance of 18 inches below the deflector of the sprinkler. When there are no sprinklers present, then this 18 inch rule does not apply, and items may be stored to the ceiling.


Aug 21 2017

Basement Storage Space in Business Occupancies

Category: Business Occupancy,Questions and Answers,StorageBKeyes @ 12:00 am
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Q: I am struggling with the Life Safety Code and need some clarification. I have an offsite clinic that is classified as a business occupancy with a basement measuring approximately 600 sq. ft. The buildings’ gas fueled furnace and water heater are located in the basement. I know we are restricted from storage of combustibles in spaces housing fuel fired equipment; but this is a large useable space that I believe can be safely used for limited combustible storage; medical & office equipment (no medical records or furniture) as long as we maintained a safe separation distance (minimum 36 inches on all sides) from the equipment. The basement is hardwired with interconnected smoke detectors connected to the main level for occupant notification. What is your opinion please?

A: Since this is a new use of the space, you need to comply with 38.3.2.1 of the 2012 Life Safety Code which refers to section 8.7. Section 8.7.1.1 would require the space to be either protected with sprinklers, or separate the hazardous area from all other areas with 1-hour fire resistive construction. The issue here is, section 38.3.2.1 considers any room used for storage (as well as furnace rooms) to be classified as hazardous, so there is no need to create a separation from the stored equipment from the furnace area. Just install sprinklers in the entire basement area, or make sure the barrier (i.e. the floor) is at least 1-hour fire rated.

You need to check with your state and local authorities to see if they have other regulations that would restrict the use of this space for storage.


Jul 31 2017

Clean Supply Room Storage

Category: Clean Supply Room,Questions and Answers,StorageBKeyes @ 12:00 am
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Q: In an OB (obstetrics) supply room, can beverages such as apple juice, water or an ice machine be stored in the room with central supply items?

A: The Life Safety Code does not address this issue, and neither does any other NFPA standard that is referenced by the Life Safety Code, as far as I can tell. Since the Life Safety Code does not address this type of arrangement, then the Life Safety Code does not prevent this arrangement.

However, I believe it is an Infection Control issue. Supply rooms are considered clean rooms and must have a positive air pressure relationship with their surrounding areas, according to the FGI guidelines. Section 2.1-2.6.8 of the 2010 FGI guidelines specifically allows ice making equipment to be located in a clean supply room. Beverages in boxes, cans or bottles would be permitted to be stored in a clean supply room, provided they have not been opened (i.e. partially opened containers).

But the FGI guidelines are guidelines and not regulations or standards. I suggest you check with your infection control practitioner and discuss the issue with him/her. In my way of thinking, they would have final say on the issue since the Life Safety Code does not address the issue.


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.


Jun 28 2017

Converting a Cath Lab Procedure Room to Storage

Category: Questions and Answers,StorageBKeyes @ 12:00 am
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Q: I have a procedure room in our Cath Lab that Administration wants to convert to a storage room. The building is fully sprinkled and as I look at NFPA 18.3.2.1 of the 2012 LSC, it refers me to section 8.7. It would seem that I could use this room for hazardous storage (combustibles) as long as I have a smoke barrier and a self-closing 20-minute door, because that is what section 8.7 permits. The room is over 100 square feet. Other storage rooms in this building are protected with a 1-hour fire rated wall system, that includes a 45-minute fire rated door assembly… so, can I or can’t I use non-rated smoke partitions for this new storage room?

A: Well… not quite. You have the right idea, but section 18.3.2.1 of the 2012 LSC over-rides section 8.7. Take a look at 18.3.2.1 which says any hazardous area shall be protected in accordance with section 8.7, and the areas described in Table 18.3.2.1 shall be protected as indicated. Table 18.3.2.1 says storage rooms larger than 100 square feet and storing combustible material requires 1-hour fire rated barriers. You state your former Cath lab procedure room is more than 100 square feet, so by the looks of things, this is the governing statement on new hazardous rooms.

However, there may be an exception that might apply to your situation. There is a new chapter in the 2012 LSC that was not in the 2000 edition: Chapter 43, which is on building rehabilitation. Take a look at 43.7.1.1 which says a change of use that does not involve a change of occupancy classification shall comply with the requirements applicable to the new use in accordance with the applicable existing occupancy chapter, unless the change of use creates a hazardous contents area as addressed in 43.7.1.2.

Looking at 43.7.1.2 (2), it says for existing healthcare occupancies protected throughout by an approved, supervised automatic sprinkler system in accordance with 9.7.1.1 (1), where a change in use of a room or space not exceeding 250 square feet results in a room or space that is described by 19.3.2.1.5 (7), the requirements for new construction shall not apply, provided that the enclosure meets the requirements of 19.3.2.1.2 through 19.3.2.1.4.

Okay… what this is saying is the change in use of the Cath lab procedure room to a storage room that is a hazardous room, does not have to meet new construction requirements for hazardous rooms (i.e. 1-hour fire rated barriers and ¾ hour fire rated door assembly), but may comply with existing construction requirements for hazardous rooms (i.e. smoke partitions and non-rated self-closing door), PROVIDED:

  • The room does not exceed 250 square feet
  • The entire building is protected with sprinklers.

Measure the area of the old Cath lab procedure room. If it does not exceed 250 square feet, then you do not have to meet 1-hour fire rated barrier requirements. However, if it does exceed 250 square feet, then I’m sorry to say, you do have to meet 1-hour fire rated barrier requirements, with a ¾ hour fire rated door assembly.


Mar 16 2017

Distance to a Storage Shed

Category: Construction,Questions and Answers,StorageBKeyes @ 12:00 am
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Q: A question that keeps coming my way pertains to out-buildings like sheds that LTC providers want to place next to their nursing homes to use for storage. Is there any minimal distance that the out-building must be away from the protected facility?  The number that I keep hearing from people is 10 feet of clearance from the protected building but I have not been able to confirm that as a requirement or a best practice.

A: No… there does not seem to be a set number of feet for a non-compliant outbuilding that needs to be from a healthcare occupancy, written into the Life Safety Code. I was at a seminar recently where that question came up and the instructor admitted there was no definite set-back required. But… like everything else that is not definitive in the Life Safety Code, the AHJ can interpret (decide) what the set-back should be. I too have heard 10 feet is the distance a non-compliant building needs to be from a healthcare occupancy without a 2-hour fire rated separation. That is actually a sound interpretation, based on other Life Safety Code requirements. Take a look at section 7.2.2.5.2 and 7.2.2.6.3 of the 2012 LSC which discusses the need for a 10 foot section of wall to be 1-hour fire rated when the fire rated wall intersects with an outside barrier at an angle less than 180 degrees. While that does not specifically refer to a set-back of a non-compliant building, it does provide you with a distance to go on.


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