Standard LS.02.01.30, EP 24 requires:
The organization meets all other Life Safety Code fire and smoke protection requirements related to NFPA 101-2000: 18/19.3.
and….
Standard LS.03.01.30, EP 20 requires:
The organization meets all other Life Safety Code fire and smoke protection requirements related to NFPA 101-2000: 20/219.3.
The Joint Commission’s accepted amount of alcohol-based hand rub permitted within a single smoke compartment is explained in the following paragraphs.
Background
The following programs are required by the National Patient Safety Goal NPSG.07.01.01 to comply World Health Organization (WHO) hand hygiene guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines:
- Ambulatory care centers
- Behavioral health care facilities
- Critical access hospitals
- Disease-specific care organizations
- Home care agencies
- Hospitals
- Laboratories
- Long term care organizations, including Medicare/Medicaid certification-based long term care organizations
- Office-based surgery centers
According to hand hygiene guidelines, when hands have no visible soil, they may be disinfected with either an alcohol-based hand rub (ABHR) or soap and water; however, when visible soiling is evident, soap and water must be used. Staff is encouraged to use ABHR when no soiling is present and recommends that all health care organizations make ABHR available and also is to be made available for staff as required through NPSG.07.01.01.
Several studies have confirmed the efficacy of ABHR and have demonstrated higher levels of compliance with hand hygiene recommendations when ABHR dispensers are located just outside of patients’ rooms. In most organizations, accommodation of this kind would result in placement of dispensers in egress corridors. This is in accordance with The Centers for Medicare & Medicaid Services (CMS) and the National Fire Protection Association (NFPA), which have determined that organizations may place ABHR dispensers outside patients’ rooms in egress corridors.
Acceptable Practices
The Joint Commission allows ABHR dispensers in corridors, provided the following conditions are met:
- 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 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.
ABHR Gel: Permissible Volume
Permissible volumes of an ABHR gel are as follows:
- Each smoke compartment may contain a maximum aggregate of 10 gallons (37.8 liters) of ABHR gel in dispensers and a maximum of 5 gallons (18.9 liters) in storage.
- The maximum individual dispenser fluid capacity is 0.3 gallons (1.2 liters) 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 (2.0 liters).
ABHR Foam: Permissible Location and Volume
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.
Risk Assessment to Manage Risks
The Joint Commission’s official stance on ABHR is based on the latest information in the NFPA 101-2000, Life Safety Code®.* As with other areas of the LSC, organizations may not meet all the requirements completely but may still provide an equivalent level of safety through assessing and managing the specific construction, systems, or operation of an area. Likewise, an organization that cannot meet all the requirements outlined in this article may perform a product-specific risk assessment of the ABHR product using product literature and determine alternative methods to achieve an equivalent level of safety.
* Life Safety Code® is a registered trademark of the National Fire Protection Association, Quincy, MA.