Fire rules put damper on use of alcohol rubs

Flammable substances prohibited in hallways

Hospitals seeking to make alcohol-based hand gels as accessible as possible have run into a firewall. Some state or local fire marshals have prohibited dispensers in corridors because of concerns about flammability.

Even if the local fire marshal gives it a thumbs up, hospitals face another barrier: The Center for Medicare & Medicaid Services (CMS) does not allow the dispensers in hallways, notes Susan McLaughlin, MBA, CHSP, MT(ASCP)SC, president of SBM Consulting Ltd. of Barrington, IL, which specializes in health care safety and regulatory compliance.

"If you’re trying to follow the letter of the law, don’t put them in the corridor right now even if your fire marshal says it’s OK," adds McLaughlin, who is also first vice chair of the health care section executive board of the National Fire Protection Association (NFPA).

"If you’re going to make new installations [of dispensers], put them in the [patient] rooms or the [patient] suites, not above light switches or outlets, and store in nonflammable cabinets," she advises.

Everyone agrees that alcohol-based hand gels can help prevent nosocomial infections, and deaths. Improving hand hygiene is one of the National Patient Safety Goals of the Joint Commission on Accreditation of Healthcare Organizations.

No fires, injuries, or deaths have been linked to the flammable hand gels. But the location of the dispensers has become a controversial issue. Fatal nursing home fires in Hartford, CT, and Nashville, TN, last year highlighted the dangers posed to nonambulatory patients.

But do alcohol-based gel dispensers really provide a significant additional risk? Fire protection agencies have been studying that question and seem poised to give them a qualified endorsement.

"Very few [hospital patients or employees] die as a result of fire," says Bob Shewbrooks, CFPS, safety officer of Graduate Hospital in Philadelphia and president of the Hospital Fire Marshals Association in Philadelphia. "Life is the issue. If we can save lives by having [gels that reduce infections], then we felt it was a good thing. We don’t see [dispensers] as an ignition source."

New hand hygiene guidelines came about after years of research into hand washing, gel use, and disease transmission. The findings, presented by the Centers for Disease Control and Prevention in 2002, are clear: Alcohol-based hand gels are effective at killing germs, they are less irritating to the skin, and they can be more convenient than soap and water.

Proponents of the gels can now add another study finding to the list. The American Society for Healthcare Engineering (ASHE) of the American Hospital Association commissioned a fire-modeling study of how the hand rubs would respond to a fire in a "typical patient care environment.

"The study results indicate that installing hand-rub dispensers is acceptable in both corridor and suite location[s]," the ASHE study concluded. "The results also showed the spacing of dispensers at or near each patient room entrance not to be a significant risk for additional ignition and involvement of more than one dispenser."

Ironically, the dispensers currently are allowed in patient rooms — where fires are more likely to start, notes Shewbrooks.

An analysis of hospital fires found that they are most likely to originate in the kitchen (20%), patient room (11%), or laundry (9%).1

A Healthcare Interpretation Task Force — made up of various organizations with jurisdiction, including NFPA, the Joint Commission, and CMS — is reviewing the ASHE study and considering whether to alter current recommendations. ASHE recommends that alcohol-based gel or liquid containers installed in an "egress corridor" should not be larger than 1.2 liters and should not project more than 3.5 inches from the wall. They should not be installed above electrical outlets or near any other potential source of ignition.

"ASHE submitted a tentative interim amendment to the NFPA to allow for mounting of these materials in the corridor," says McLaughlin, noting that there also will be a proposal to revise the next NFPA Life Safety Codes, which come out in 2006.

One complicating factor: Hospitals and nursing homes are covered by the same codes. Because of the nursing homes fires, there are greater concerns about flammable materials in those facilities.

Meanwhile, hospitals must try to navigate the various rules and rule-enforcing authorities. "Organizations always have to comply with the strictest authority having jurisdiction," she adds.

At William W. Backus Hospital in Norwich, CT, dispensers have been placed in patient rooms. But Jonathan S. Mittelman, MD, MPH, medical director of occupational medicine/employee health services, would prefer to install convenient dispensers outside the rooms in the hallways.

"We wanted to put them in hallways so that people are using them between every patient," he says. "The driving force is convenience of use."

Mittelman, who also serves as a volunteer firefighter, is well aware of the potential dangers of flammable materials. But he notes that the hospital uses many other flammable materials, such as oxygen lines, without incident. Other precautions, such as sprinklers, could reduce the risk. "We have our hazards, but we have ways of handling them."


1. Jaeger TW, Leaver CM, Glenn R. Alcohol-Based Hand rub Solution Fire Modeling Analysis Report. Chicago: American Society for Healthcare Engineering; Aug. 22, 2003. Web: