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… Are You Nuts…?!

Q: I have a Medical Office Building with multiple exam rooms, and it is constructed with 5-foot wide corridors. This building followed design reviews including Life Safety expertise from the local AHJ. In many cases, an alcohol-based hand-rub (ABHR) sanitizer dispenser is located just outside the exam rooms in the egress corridor. Why are you saying these dispensers are not permitted especially when section 19.3.2.6 says they are? Are you nuts…?

A: Well, I may be a bit crazy, but I’m pretty sure ABHR dispensers are not permitted in medical office building corridors.

Section 19.3.2.6 is applicable for healthcare occupancies, such as hospitals, nursing homes, long-term care facilities, etc. And section 21.3.2.6 is applicable for ambulatory health care occupancies such as Ambulatory Surgical Centers. But these sections are only applicable to their respective occupancies, and the typical Medical Office Building is not any of these… they are business occupancies. And unfortunately for you, there is nothing similar in business occupancy chapters 38 and 39 for ABHR dispensers.

It really all starts with section 8.7.3.2 which says no storage or handling of flammable liquids shall be permitted in any location where such storage would jeopardize egress from the structure. The ABHR gel or foam product in these dispensers have a high enough alcohol content to cause it to be classified as a Class 1-B flammable liquid, according to NFPA 30. So, according to 8.7.3.2, flammable liquids (i.e. ABHR dispensers) cannot be used in a corridor of a facility. But sections 19.3.2.6 and 21.3.2.6 permit ABHR product and dispensers in corridors of healthcare occupancies and ambulatory health care occupancies… so what’s up with this conflict?

According to section 4.4.2.3 whenever the occupancy chapter differs with the core chapters, then the occupancy chapter governs. So, on the issue of ABHR dispensers, they are permitted in the corridors of healthcare occupancies and ambulatory health care occupancies because those chapters have specific language that over-rides the core chapter.

But not so for business occupancies. Chapters 38 & 39 are silent regarding ABHR dispensers. Therefore, you cannot have ABHR dispensers in the corridors of business occupancies because they are a flammable liquid.

Even if the Medical Office Building was re-classified as ambulatory health care occupancy (I don’t recommend it), you still could not place the ABHR dispensers in the corridors because the corridors are not 6-feet wide.

I don’t see that this issue will likely be cited by surveyors, for a couple of reasons: 1) Not all surveyors know and understand this issue very well. They know ABHR dispensers are permitted in hospitals and figure the requirements for hospitals are more restrictive than business occupancies, and would allow them in a medical office building; 2) Typically, the surveyors who survey medical buildings (i.e. business occupancies) are nurse surveyors or physician surveyors…. not Life Safety surveyors, so they would not be as familiar with the LSC on this issue.

ABHR Dispensers in Business Occupancy Corridors

Q: Do you know of any other information on alcohol-based hand-rub (ABHR) dispensers not allowed in the egress corridors of business occupancies? I need more information than what you have already posted:

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 Life Safety Code 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 Life Safety Code allows ABHR dispensers in corridors of healthcare occupancies and in ambulatory health care occupancies…. but not business occupancies.

A: Nope… that’s all there is. It is very clear that the Life Safety Code does not permit the storage or handling of flammable liquids in egress areas, based on section 8.7.3.2. However, the Life Safety Code makes specific exceptions for healthcare occupancies (i.e. hospitals, nursing homes, long term care centers, etc.) and ambulatory health care occupancies (ASC, physical therapy units) based on section 18/19. 3.2.6 and 20/21.3.2.6. The problem is, these exceptions do not apply to Business Occupancies and chapters 38/39 do not contain anything that would over-ride 8.7.3.2.

ABHR Dispensers

Q: In a business occupancy building, can alcohol based hand-rub dispensers be placed over carpeted area with no sprinklers?

A: Maybe yes and maybe no… It all depends on which AHJ is looking at your business occupancy.

Section 19.3.2.6 (8) of the 2012 LSC requires ABHR dispensers that are mounted over carpets, to only be in sprinklered smoke compartments. But this only applies to healthcare occupancies, and section 21.3.2.6 has similar language for ambulatory healthcare occupancies. The problem is, there is nothing written in chapters 38 or 39 regarding the installation of ABHR dispensers in business occupancies.

Since nothing is written in the business occupancy chapters, one may think there are no limitations, and the ABHR dispensers may be placed wherever you want without regard to regulations. Some AHJs may agree, and allow the ABHR dispensers be installed over carpet in an unsprinklered area. But the AHJs with healthcare experience and knowledge probably will not, based on their understanding of chapters 19 and 21. And, this is not an incorrect process, since they know these regulations regarding ABHR dispensers and can apply them to a business occupancy based on safety-related issues. Section 4.6.1.2 supports this concept.

But please understand, section 8.7.3.2 of the 2012 LSC prohibits the handling and storage of flammable liquids where it would jeopardize egress. This means ABHR dispensers are not permitted in egress corridor. Chapter 18/19 and 20/21 specifically permit ABHR dispensers in corridor so that over-rides section 8.7.3.2. But the business occupancy chapters 38 and 39 do not have this language to over-ride 8.7.3.2, so that means ABHR dispensers are not permitted in egress corridor of business occupancies.

My advice is follow the same regulations for ABHR dispensers found in 19.3.2.6 for business occupancies, with the exception that ABHR dispensers are not permitted in egress corridors of business occupancies.

Alcohol Disinfectant Wipes

Q: What is your opinion on alcohol based disinfectant wipes and their inclusion in the aggregate amount of flammable liquids in a smoke compartment?  We are considering a product that contains 55% isopropyl alcohol and would be 857ml.  There is one opinion posted online that includes these products in the NFPA 30 standard compliance.

A: I would agree with the concept that any alcohol product would contribute to the aggregate total of ABHR liquids or aerosols to not exceed 10 gallons in dispensers per smoke compartment. Therefore, if you had one 857 ml dispenser of alcohol-based disinfectant wipes, then you would be limited to 36 one-liter ABHR dispensers per smoke compartment so you would not exceed 10 gallons of product in dispensers per smoke compartment. This would be consistent with section 19.3.2.6 (5) of the 2012 LSC.

ABHR Dispensers in Business Occupancies

Q: In the 2012 edition of the Life Safety Code, section 19.3.2.6 (9) states dispensers of alcohol based hand rub (ABHR) solution are permitted to be installed directly over carpeted floors in fully sprinkled smoke compartments. My question is: Does this go with business occupancies as well?

A: I would say surveyors would likely ‘borrow’ from chapter 19 and apply certain requirements regarding ABHR dispensers in business occupancies. But there is a huge difference between healthcare occupancies and business occupancies for ABHR dispensers. Section 19.3.2.6 is a healthcare occupancy chapter, and anything written in chapter 19 applies to just existing healthcare occupancies. The Life Safety Code requirements for a business occupancy are found in chapter 38 for new construction business occupancies and chapter 39 for existing business occupancies.

It is interesting to note that chapters 38 & 39 do not have the similar language found in chapters 18 & 19 for healthcare occupancies that permit ABHR dispensers in corridors (i.e. 18/19.3.2.6). Therefore, section 38/39.3.2.1 is the applicable standard and must be followed, which says hazardous areas must comply 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. Where chapters 18 & 19 for healthcare occupancies have exceptions that actually permit ABHR dispensers in corridors, chapters 38 & 39 do not for business occupancies. In fact, chapters 38 & 39 actually requires compliance with section 8.7.3.2 which prohibits the handling of flammable liquids (and ABHR solution is considered a flammable liquid) in an egress.

That is why ABHR dispensers are not permitted in business occupancy corridors. Since the business occupancy chapters do not address ABHR dispensers, other than saying flammable liquids cannot be stored or handled in the egress, surveyors would likely follow the chapter 19 requirements on ABHR dispensers for other regulatory requirements in business occupancies. They could easily enforce the width separation and the requirement to keep the dispenser away from ignition sources and other requirements. Since chapters 38 & 39 are silent on the issue of ABHR dispensers, the surveyors could ‘borrow’ from chapter 19 and enforce that, as long as it does not conflict with section 8.7.3.2.

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.