ABHR Dispensers in Patient Rooms

Q: In the 2012 LSC concerning alcohol based hand rub (ABHR) dispensers in a hospital setting, is there a limit to the number of dispensers that can be in a patient sleeping room? We are wanting to have additional dispensers available in the room, such as 1 on the wall, one attached to the bed and one tabletop dispenser at the nurse workstation in the room. In the 2012 codes, would this number be allowed?

A: There is not a limit to the number of ABHR dispensers permitted in a patient room, but there is a limit to the quantity of ABHR product in dispensers per smoke compartment. You are limited to 10 gallons of ABHR product in dispensers per smoke compartment. If, for instance, each dispenser is 1 liter of product, then that means you can only have 37 dispensers per smoke compartment.

Now, the 2012 LSC does allow you to have one dispenser per room not contribute to the aggregate total of ABHR product in dispensers per smoke compartment, so if you have 12 patient rooms in the smoke compartment and one dispenser in each room, then that means you could increase the total ABHR dispensers from 37 to 49.  And you must include in the aggregate total all pocket-sized dispensers and all table-top dispensers. This rule is not limited to just wall-mounted dispensers.

Brad Keyes
Brad Keyes, CHSP

Brad is a former advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor. He guides clients through  organizational assessment; management training; ongoing coaching of task groups; and extensive one-on-one coaching of facility leaders. He analyzes and develops leadership effectiveness and efficiency in work processes, focusing on assessing an organization’s preparedness for a survey, evaluating processes in achieving preparedness, and guiding organizations toward compliance. 

As a presenter at national seminars, regional conferences, and audio conferences, Brad teaches the Keyes Life Safety Boot Camp series to various groups and organizations. He is the author or co-author of many HCPro books, including the best-selling  Analyzing the Hospital Life Safety Survey, now in its 3rd edition. Brad has also authored a variety of articles in numerous publications addressing features of life safety and fire protection, as well as white papers and articles on the Building Maintenance Program. Currently serving as the contributing editor of the monthly HCPro newsletter Healthcare Life Safety Compliance  gives Brad further insight into the industry’s trends and best practices.