Fire and Alcohol: Hand-Hygiene Plans Getting Hosed Down by Safety Officials

By Gary Evans, Hospital Infection Control editor

The nationwide switch to alcohol hand rubs is running afoul of fire marshals who fear the flammable products might accelerate a hospital blaze.

Loretta Fauerbach, MS, CIC, director of infection control at Shands Hospital at the University of Florida in Gainesville, recently described the problem to infection control advisors at the Centers for Disease Control and Prevention (CDC).

The Joint Commission for Accreditation of Healthcare Organizations also has weighed in on the issue (see page 134).

"Fire marshals are reacting to the presence of alcohol-based hand-hygiene agents," Fauerbach told the CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC). "In fact, if [ICPs] are posting dispensers in the hallway, they are getting cited." A liaison member of HICPAC representing the Association for Professionals in Infection Control and Epidemiology (APIC), Fauerbach said APIC is working with hospital safety and engineering groups to resolve the situation.

"It was sort of one of these things that nobody in infection control or HICPAC thought of, and many institutions [in] several states are being bombarded by their fire marshals," she told the committee. "We hoped it would go away, but it has reached a crescendo."

While the issue may prove to be only a short-term setback, it certainly undermines the momentum of the CDC’s highly touted answer to the longstanding problem of poor hand-washing compliance. The alcohol-based rubs are quick, effective, don’t require a sink, and unfortunately, are flammable.

"[The CDC] basically came from the standpoint of this is what is good for cleaning your hands," said William M. Wagner, ScD, director of Southeast Region Safety Management Services Inc., a medical consulting firm in Atlanta.

"You have to have a certain amount of active ingredients—in this case, ethanol and isopropyl—as the agent to do the killing," he said. "It does work, but they never thought about where people were going to put these things. And that raised the flammability issue. And [alcohol] foams are a flammable liquid under pressure, so you now have a Roman candle if it gets hot."

Rules are Rules

The National Fire Protection Association (NFPA) standards for fire safety codes for hospitals prohibit anything that limits the egress of patients out of their rooms, he added. "The alcohol in the hallway can do that," Wagner said. "If there is a fire, you have a flammable liquid that can enhance the fire. The question that comes up is how the [local] jurisdiction is going to interpret that. The authority having jurisdiction’ can be the local fire marshal, county fire marshal, or whoever has been given the responsibility for fire in that location. They are the ones who started saying, No, you can’t do this,’ after some hospitals put up 500 bottles outside of every room in the hospital."

There is a growing general perception that fire marshals have less problem with the alcohol rubs if they are in the patient room as opposed to mounted in the hallway.

"We are going to be putting them in our rooms," said Jo Middlebrooks, RN, CIC, infection control coordinator at Henry Medical Center in Stockbridge, Ga.

"But you know we use alcohol every day all over the hospital. We use alcohol wipes to prep before we administer something into an IV line. We use tons of alcohol a day. So what is the difference?" she asked.

In any case, ICPs should contact their local fire officials regarding placement and storage of the items. "People should make an assessment before they start to put them up," Wagner said. "That should have been part of their actual ordering process. When you read the [ordering] sheet and it says flammable liquids, that raises [issues about] the storage of it and where you are going to put it in the [patient care area]."

Addressing the issue in the guidelines, HICPAC reminded that: "Alcohols are flammable. Flash-points of alcohol-based hand rubs range from 21ºC to 24ºC, depending on the type and concentration of alcohol present. As a result, alcohol-based hand rubs should be stored away from high temperatures or flames in accordance with National Fire Protection Agency recommendations. In Europe, where alcohol-based hand rubs have been used extensively for years, the incidence of fires associated with such products has been low.1

"One recent US report described a flash fire that occurred as a result of an unusual series of events, which included a health care worker applying an alcohol gel to her hands, immediately removing a polyester isolation gown, and then touching a metal door before the alcohol had evaporated.2 Removing the polyester gown created a substantial amount of static electricity that generated an audible static spark when the worker touched the metal door, igniting the unevaporated alcohol on her hands,"3 HICPAC said.

"This incident emphasizes the need to rub hands together after application of alcohol-based products until all the alcohol has evaporated."3

Another concern is that the problem will open up the market to low-alcohol, nonflammable products, which are not strong enough to decontaminate the hands. The CDC recommends an alcohol content of least 60% for effective hand hygiene, but some of the nonflammable products have only 10% alcohol.

"I have been talking to some of my old colleagues at CDC, and they are worried that people are going to start buying these gels that say nonflammable," Wagner said.

"If they are nonflammable, they don’t have enough alcohol in them to deactivate the organisms."

References

1. Widmer AF. Replace hand washing with use of a waterless alcohol hand rub? Clin Infect Dis. 2000; 31:136-143.

2. Bryant KA, et al. Flash fire associated with the use of alcohol-based antiseptic agent. Am J Infect Control. 2002;30:256-257.

3. Centers for Disease Control and Prevention. Guideline for hand hygiene in health care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Morb Mortal Wkly Rep MMWR. 2002;51(RR16):1-44.

This article was published in the April 2003 issue of Hospital Infection Control.