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/ (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/ (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