JCAHO Addresses Issue of Fire, Alcohol Rubs

Dear Editor: There has been a lot of discussion going on in recent weeks in regards to the use of alcohol-based hand-hygiene products in health care settings. We feel that the spotlight has now been shined upon the judicious use of these products since the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) released its Sentinel Event Alert pertaining to infection control practices.

JCAHO has officially come out on allowing and encouraging the use of these products to assist in reducing the spread of nosocomial infections. The debate is now centering on where to place and mount these dispensers. Many infection control practitioners and infectious disease specialists recommend mounting the dispensers just outside the patient room doorway in the egress corridor to achieve the best results in getting staff to use the dispensers. The following is our position at the moment regarding the location and installation of alcohol-based hand-sanitizing gel dispensers in health care facilities.

The 2000 edition of National Fire Protection Association (NFPA) 101 (Life Safety Code) prohibits the installation of these types of items in egress corridors.

Per section 7.3.2, (Means of Egress) these devices are prohibited unless the dispensers protrude no more than 3.5 inches into the egress corridor and are mounted at or below a height of 38 inches. Next, NFPA 101 Sec. 4.3.2 states: "No storage or handling of flammable liquids or gases shall be permitted in any location where such storage [or use of product] would jeopardize egress from the structure, unless otherwise permitted by 8.4.3.1."

Additionally, 101-19.7.5.4 prohibits placing combustible decorations in any health care occupancy unless they are flame retardant. While we realize that 101-19.7.5.4 does not precisely address alcohol gel dispensers, it is, however, a code citation that we believe comes close to addressing this issue in health care facilities.

Finally, 1999 NFPA 30, Flammable and Combustible Liquids Code, Chapter 4, would probably be another code/chapter to review for this matter. All this being said, none of these codes explicitly cite any chapter and verse specifically addressing wall-mounted alcohol-based hand-wash gel dispensers.

JCAHO recommends organizations install these dispensers not in the egress corridors, but just inside the patient’s room or whichever rooms the organization deems necessary. Do not install them above a heat/ignition source or electrical outlet. Our contention is that the typical alcohol gel dispenser used in the health care setting is of such a limited size and volume that the alcohol gels’ contribution to the hazard of acceleration of fire development or fire spread is "negligible."

This matter was discussed at the 2002 NFPA fall meeting with various authorities having jurisdiction (AHJs) including fire marshals, JCAHO, IFMA, ASHE, the NFPA Health Care Section executive board, and a host of others. Some fire marshals are concerned about the use of these alcohol gel sanitizers, and the matter is being reviewed. There will be tests performed sometime in the near future by independent agencies to determine the level of risk involved with these alcohol gel dispensers.

Again, we intend to publish any significant findings or test results in Environment of Care News as they are received.

— Submitted by: Thomas Scott Vanderhoof, Captain, US Air Force, MSC, CAAMA, AFIT, EWI, Environment of Care Fellow, Joint Commission for Accreditation of Healthcare Organizations Standards Interpretation Group, Oakbrook Terrace, Ill.