Alcohol based hand rub dispensers - Placement In Waiting Areas
What are the requirements for alcohol-based hand rub dispensers and alcohol hand wipes?
Any examples are for illustrative purposes only.
The Joint Commission allows the installation of alcohol-based hand rub (ABHR) dispensers in corridors and rooms provided the requirements of NFPA 101-2012, 18/19.3.2.6 are met. Please note that there are eleven criteria, and ALL criteria must be met in order to be in compliance. LS.02.01.30 EP6 lists 10 of the requirements, plus one dispenser per room may be excluded from the 10-gallon maximum. The 10-gallon limit per smoke compartment is applicable to the aggregate of all alcohol-based products mounted in unprotected locations within a smoke compartment. For consistency, the volume of the ABHR container (typically ounces converted to gallons) would be used in the aggregate calculation, regardless of the amount contained within at the time of review.
Additionally, there is an allowance to exclude one dispenser from the aggregate volume when located in a room, so caution should be taken when calculating volume where ABHR dispensers are located in a suite versus an individual room; that is, only one dispenser in a suite will be excluded from the aggregate volume limitations. One dispenser complying with 18/19.3.2.6 (2) or (3) per room and located in that room shall not be included in the aggregated quantity addressed in 18/19.3.2.6(5).
Alcohol-based hand wipes are not included in the 10-gallon limit per smoke compartment due to some products not listing the alcohol content and others do not actually have alcohol as their disinfecting ingredient. However, caution should be used in adding wipes to areas as they are still potentially adding to the combustible fire load and/or increase the amount of flammable materials in the area. Additionally, depending on the disinfecting ingredient, the wipes could be reviewed as a hazardous chemical; the SDS should be reviewed and appropriate actions taken. A risk assessment is not a requirement but is a recommendation.
Reference LS.02.01.30 EP6
The Joint Commission allows the installation of alcohol-based hand rub (ABHR) dispensers in corridors and rooms provided the requirements of NFPA 101-2012, 18/19.3.2.6 are met. Please note that there are eleven criteria, and ALL criteria must be met in order to be in compliance. LS.02.01.30 EP6 lists 10 of the requirements, plus one dispenser per room may be excluded from the 10-gallon maximum. The 10-gallon limit per smoke compartment is applicable to the aggregate of all alcohol-based products mounted in unprotected locations within a smoke compartment. For consistency, the volume of the ABHR container (typically ounces converted to gallons) would be used in the aggregate calculation, regardless of the amount contained within at the time of review.
Additionally, there is an allowance to exclude one dispenser from the aggregate volume when located in a room, so caution should be taken when calculating volume where ABHR dispensers are located in a suite versus an individual room; that is, only one dispenser in a suite will be excluded from the aggregate volume limitations. One dispenser complying with 18/19.3.2.6 (2) or (3) per room and located in that room shall not be included in the aggregated quantity addressed in 18/19.3.2.6(5).
Alcohol-based hand wipes are not included in the 10-gallon limit per smoke compartment due to some products not listing the alcohol content and others do not actually have alcohol as their disinfecting ingredient. However, caution should be used in adding wipes to areas as they are still potentially adding to the combustible fire load and/or increase the amount of flammable materials in the area. Additionally, depending on the disinfecting ingredient, the wipes could be reviewed as a hazardous chemical; the SDS should be reviewed and appropriate actions taken. A risk assessment is not a requirement but is a recommendation.
Reference LS.02.01.30 EP6
Manual:
Hospital and Hospital Clinics
Chapter:
Life Safety LS
First published date: April 11, 2016
This Standards FAQ was first published on this date.
This page was last updated on October 26, 2021
Get Extra Help with Books and E-books
Browse our gallery of books and e-books to find trusted prep and readiness resources, practical checklists and toolkits, and resources on specialized health care topics.
Stay Informed with Online Education
Online education is the most convenient and cost-effective way to educate your staff and minimize expenses without the need to leave your organization.
Reach Your Safety Goals with eProducts
Assessing and sustaining compliance with accreditation standards or CMS CoPs can be a challenge, but it doesn’t have to be. Rely on our proven software solutions developed by our team of industry experts.