Center for Improvement in Healthcare Quality Newsletter
January 2022

CIHQ-ARS Blog

Alcohol-Based Hand-Rub Dispensers

By: William (Billy) Kinch
The world we live in today has a focus on hand-hygiene. One of the ways healthcare workers and visitors within hospitals can maintain proper hand hygiene is by using alcohol-based hand-rub (ABHR). Alcohol is a flammable material and considered to be hazardous. For hospitals to be able to use this hazardous material there are certain fire safety precautions that must be taken.
Here is a list of those precautions as listed in NFPA 101-2012 Life Safety Code 19.3.2.6:
  • Where dispensers are installed in a corridor, the corridor shall have a minimum width of 6 feet
  • The maximum individual dispenser fluid capacity shall be as follows:
    • 0.32 gal (1.2 L) for dispensers in rooms, corridors, and areas open to corridors
    • 0.53 gal (2.0 L) for dispensers in suites of rooms
  • Where aerosol containers are used, the maximum capacity of the aerosol dispenser shall be 18 oz. and shall be limited to Level 1 aerosols
  • Dispensers shall be separated from each other by horizontal spacing of not less than 48 in.
  • Not more than an aggregate 10 gal of ABHR solution or 1135 oz of Level 1 aerosols, or a combination of liquids and Level 1 aerosols not to exceed, in total, the equivalent of 10 gal or 1135 oz, shall be in use outside of a storage cabinet in a single smoke compartment
  • One dispenser complying with the above per room and located in that room shall not be included in the aggregated quantity in use
  • Storage of quantities greater than 5 gal in a single smoke compartment shall meet the requirements of NFPA 30
  • Dispensers shall not be installed in the following locations:
    • Above an ignition source within a 1 in. horizontal distance from each side of the ignition source
    • To the side of an ignition source within a 1 in. horizontal distance from the ignition source
    • Beneath an ignition source within a 1 in. vertical distance from the ignition source
  • Dispensers installed directly over carpeted floors shall be permitted only in sprinklered smoke compartments
  • The ABHR solution shall not exceed 95 percent alcohol content by volume
  • Operation of the dispenser shall comply with the following criteria:
    • The dispenser shall not release its contents except when the dispenser is activated, either manually or automatically by touch-free activation
    • Any activation of the dispenser shall occur only when an object is placed within 4 in. of the sensing device
    • An object placed within the activation zone and left in place shall not cause more than one activation
    • The dispenser shall not dispense more solution than the amount required for hand hygiene consistent with label instructions
    • The dispenser shall be designed, constructed, and operated in a manner that ensures that accidental or malicious activation of the dispensing device is minimized
    • The dispenser shall be tested in accordance with the manufacturer’s care and use instructions each time a new refill is installed
While most items listed above are self-explanatory, there are a couple of things hospitals should be aware of. Where it states that dispensers are installed where they cannot be used maliciously has some room for interpretation from Authorities Having Jurisdiction (AHJs). Some interpretations that have been taken include not allowing ABHRs to be in rooms where pediatric patients are treated. The thinking behind this is that a pediatric patient could potentially ingest the product. Additionally, the ABHRs should not be installed in unsupervised locations for behavioral health units and dementia units.
There is a lot of discussion around the use of ABHRs in Business Occupancies. The Center’s for Medicare/Medicaid Services (CMS) requires compliance to NFPA 101-2012 edition. According to this edition, ABHRs are not permitted according to the Business Occupancy chapter. However, the 2018 edition of NFPA 101 does specifically permit the use of ABHRs in a Business Occupancy. While this edition of NFPA 101 has not been approved by CMS, AHJs have started allowing the use of ABHRs in Business Occupancies due to this change in newer editions of the Code. Organizations should follow-up with their AHJs to determine if they are permitting this.
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