JCAHO Update for Infection Control

Joint Commission Q&A on alcohol hand rubs

Complying with National Patient Safety Goals

In February, the Joint Commission on Accreditation of Healthcare Organizations provided some new answers to commonly asked questions about complying with its National Patient Safety Goal on hand hygiene.

Questions and answers dealing with alcohol hand rubs, compliance, and fire hazards include the following:

Q: Do we have to use alcohol-based hand cleaners?

A: Accredited organizations are required to provide health care workers with a readily accessible alcohol-based hand rub product. However, use of an alcohol-based hand rub cleaner by any individual health care worker is not required. The Centers for Disease Control and Prevention guidelines describe when this type of cleaner may be used instead of soap and water. If you choose not to use it, then soap and water should be used instead.

Q: Isn't the alcohol-based hand sanitizing gel flammable? Should we be concerned about a fire hazard?

A: The typical alcohol-based hand rub (ABHR) dispensers used in the health care setting are of such limited size and volume that their contribution to the development, acceleration or spread of fire in most situations is small. In a recent survey of 800 facilities reporting a cumulative 1,430 years of hand rub use, no fires attributable to or involving a hand rub dispenser were reported. Studies have shown significantly better compliance when the dispensers are located just outside the patient's room (when permissible) rather than just inside.

The National Fire Protection Agency (NFPA) has modified Life Safety Code (LSC) requirements to allow for installation of ABHR gel dispensers in egress corridors, subject to certain conditions being met (see below). The Centers for Medicare & Medicaid Services (CMS) is in the process of amending its rules to reflect the NFPA position. The "Interim Final Rule" to permit placement of alcohol-based hand rub dispensers in egress corridors, in agreement with the LSC amendment, was published in the Federal Register on March 25, 2005. Note that local or state fire code requirements may differ from the national codes; therefore, you should determine and follow the requirements for your particular locale. The best resource for this information is your local fire marshal.

Q: What are the "conditions" that have to be met to be able to install ABHR dispensers in egress corridors?

A: Location conditions and permissible volume specifications for gel ABHR dispensers to be installed in egress corridors are as follows:

  • The corridor width is 6 feet or greater and dispensers are at least 4 feet apart.
  • The dispensers are not installed over or directly adjacent to an ignition source, such as an electrical outlet or switch. Adjacent is defined as being at least 6 inches from the center of the dispenser to an ignition source.
  • In locations with carpeted floor coverings, dispensers installed directly over carpeted surfaces are permitted only in sprinklered smoke compartments.
  • Each smoke compartment may contain a maximum aggregate of 10 gallons of ABHR gel in dispensers and a maximum of 5 gallons in storage.
  • The maximum individual dispenser fluid capacity is 0.3 gallons for dispensers in rooms, corridors, and areas open to corridors.
  • The maximum dispenser size for individual dispensers in areas designated as suites of rooms is 0.5 gallons.

Q: The ruling on placement of ABHR dispensers in egress corridors specifically refers to gel ABHR dispensers? We would prefer to use the foam product. Do the same rules apply?

A: The situation is a little different with respect to foam ABHR products because all of the testing upon which the NFPA and CMS decisions were based were done on the gel product, not on foam. However, industry experts have indicated that small-quantity ABHR foam dispensers may be equivalent to ABHR gel. Therefore, pending further review, the Joint Commission will allow any ABHR foam installation that meets the location criteria stated above for ABHR gel. Volumes of ABHR foam are based on suppliers' recommendations and in no case exceed the permissible volumes for ABHR gel as defined above. In the event that subsequent testing demonstrates a safety concern relating to foam dispensers in egress corridors, the Joint Commission reserves the right to modify its position on the acceptability of such installations. In that event, previously installed dispensers would be subject to the newer restrictions; that is, they would not be "grandfathered," and noncompliant installations would have to be removed.