OFM - TG-02-2011: Safe Practices for the Use of Alcohol-Based Hand Rub

OFM Guideline

Office of the Fire Marshal

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OFM-TG-02-2011
Safe Practices for the Use of Alcohol-Based Hand Rub

 

July 2011

 

TABLE OF CONTENTS

SECTION

Abstract

Acknowledgement

1.0 INTRODUCTION

2.0 CARE AND TREATMENT OCCUPANCIES

2.1 Scope
2.2 Open Flames
2.3 Sources of Ignition
2.4 Corridors
2.5 Rooms and Suites
2.6 Unsupervised Areas
2.7 Public and Outpatient Area
2.8 Multi-Dispenser Stations
2.9 Carpeted Areas
2.10 Excess Stock

APPENDIX A – Additional Guidance Notes

July, 2011
OFM Section: Fire Safety Standards at (416) 325-3100
The reproduction of this guideline for non-commercial purposes is permitted and encouraged. Permission to reproduce the guideline for commercial purposes must be obtained from the Office of the Fire Marshal, Ontario.


Abstract

This document provides information to address potential fire safety hazards related to the placement and use of alcohol-based hand rub (ABHR) in buildings. ABHR products are dispensed in small quantities thus the fire hazards they present are minimal. However, certain precautions are recommended to achieve an acceptable level of fire safety.

The scope of the guideline is limited to care and treatment occupancies, and related ancillary spaces

Acknowledgement

The Office of the Fire Marshal gratefully acknowledges the contribution of the various health care and fire services stakeholders who provided valuable feedback towards the development of this guideline.

1.0 INTRODUCTION

Containers of alcohol-based hand rub (ABHR) are typically located on wall-mounted holders from which a small amount can be dispensed to sanitize hands. Two types of hand rub that have been identified are the gel/liquid type and the foam type (aerosol and non-aerosol). The gel/liquid and non‑aerosol foam products are typically classified as a Class IB flammable liquid under Division B, Sentence 4.1.2.1.(2) of the Fire Code. The aerosol foam type product is typically classified as a Level 1 aerosol by the National Fire Protection Association (see NFPA‑30B).

While ABHR products are subject to the general provisions in Division B, Section 4.1 of the Fire Code, they are exempt from Division B, Section 4.2 of the Fire Code as a pharmaceutical product in closed containers having a capacity of not more than 5 L [see Clause 4.2.1.1.(2)(d)]. Consequently, the installation and use of ABHR should be guided by Division B, Section 4.1 of the Fire Code and this document.

2.0 CARE AND TREATMENT OCCUPANCIES

2.1 Scope

Care and treatment occupancies are occupancies in which persons receive special care and treatment and include hospitals, homes for special care and long-term care homes. [See Appendix A]

2.2 Open Flames

Avoid exposure to open flames (e.g. smoker's materials) during and immediately after application.

In oxygen-enriched environments, ensure hands are completely dry before touching equipment, devices, bedding or patients/residents.

Users should be cautioned on the potential fire hazards through instruction and/or signage. [See Appendix A]

2.3 Sources of Ignition

Locate dispensers away from potential sources of ignition such as radiant heaters that could raise the container temperatures to above 49ºC (120ºF) and at least 1 m (3 feet) from any open flame.

Do not install dispensers above electrical switches and outlets for a horizontal distance of 150 mm (6 inches) to each side of the electrical device or closer than 150 mm (6 inches) to the sides of electrical switches and outlets. [See Appendix A]

2.4 Corridors

Where dispensers are provided in corridors, not more than one dispenser of maximum 1.2 L (gel/liquid/non-aerosol foam) capacity shall be located at each entry into a room.

NOTE: Level 1, 2 and 3 classified aerosols shall not be used in corridors.

2.5 Rooms and Suites

Where dispensers are provided in sleeping rooms, treatment rooms and in other rooms or suites, not more than one dispenser of maximum 1.2 L (gel/liquid/non-aerosol foam) or 0.51 Kg. (aerosol) capacity should be provided at each point of care (i.e. at each bed or treatment station), exit point, and common work point (e.g., charting station, medication station). A minimum 1.2 m (4 feet) horizontal centre to centre spacing should be maintained between dispensers. [See Appendix A]

2.6 Unsupervised Areas

Particular care should be taken to use secure dispensers in unsupervised areas and in areas where there is a risk of misuse. [See Appendix A]

NOTE: Dispensers shall not be installed in concealed spaces such as elevators.

2.7 Public and Outpatient Areas

Placement of dispensers at building entrances and in public and outpatient areas should be consistent with the dispenser type, capacity and horizontal spacing recommendations for corridors, rooms and suites.

2.8 Multi-Dispenser Stations

Use of multi-dispenser stations in patient/resident care areas is not recommended. If utilised at building entrances and other public spaces, it is recommended that the following precautions be implemented:

  • Except for the mounting backboard, free-standing stations should be constructed primarily of noncombustible materials;
  • Individual dispensers should be of maximum 1.2 L (gel/liquid/non-aerosol foam) capacity;
  • The maximum aggregate quantity of ABHR at any one entrance area or vestibule should not exceed 3.6 L (gel/liquid/non-aerosol foam);
  • If more than one dispenser is placed on the walls of an entrance area or vestibule, a minimum 1.2 m (4 feet) horizontal centre to centre spacing should be maintained between the dispensers. In the case of a free-standing station, the dispensers should be placed on offset faces of the station such that a minimum 0.30 m (1 foot) horizontal centre to centre spacing is achieved. In either circumstance, the dispensers may instead be separated by a solid divider, of at least the same depth and height of the dispenser, so as to limit fire spread between the individual dispensers;
  • Level 1, 2 and 3 classified aerosols shall not be used in the stations.

Consult with the local fire department for alternative arrangements.

2.9 Carpeted Areas

Dispensers shall not be installed directly over carpeted surfaces except if the floor area is sprinklered or measures are taken to control accumulation of product in the carpet.

2.10 Excess Stock

Stock of ABHR product not for immediate use shall be located in a storage room protected with a 1-hour fire separation. Alternatively, excess stock may be stored in a cabinet conforming to Division B, Subsection 4.2.10. of the Fire Code.

Bulk dispensing of ABHR product shall only be undertaken in rooms conforming to Division B, Part 4 of the Fire Code.

The Fire Code is electronically accessible through the government’s e-Laws website at
http://www.e-laws.gov.on.ca/html/source/regs/english/2007/elaws_src_regs_r07213_e.htm

Appendix A
Additional Guidance Notes

A-2.1 Scope

Although the scope of this guideline is limited to care and treatment occupancies such as hospitals, homes for special care and long-term care homes, the principles may be equally applicable to other occupancies in which residents receive some form of special or supervisory care such as retirement homes and group homes. The principles may be similarly extended to community health clinics and related occupancies.

A-2.2 Open Flames

Cautionary signage on the potential fire hazards associated with the use of ABHR should be legible to users and include a statement such as “Fire Hazard – Ensure Hands are Completely Dry after Use”. Bilingual or multilingual signs or symbol placards may be appropriate based on the population served. Signs should be located at primary and secondary public entrances in close proximity to dispensers, and near dispensers serving spaces containing oxygen-enriched environments or highly energized equipment.

A-2.3 Sources of Ignition

The measurement of 150 mm (6 inches) is from the centre of the ABHR dispenser to the closest edge of an electrical switch or outlet.

A-2.5 Rooms and Suites

The recommended placement of ABHR dispensers within rooms and suites seeks to achieve a reasonable balance between health and fire safety needs. It is, however, not intended to preclude the placement of additional dispensers where dictated by health or flow of care needs. To avoid the possibility of multiple dispenser involvement in the event of a fire, care should be taken to ensure a minimum 1.2 m (4 feet) horizontal centre to centre spacing between dispensers.

A-2.6 Unsupervised Areas

Lockable dispensers or certain dispenser designs are some ways in which to meet the intent of this recommendation, however, there may be other ways in which to secure the dispensers so as to discourage their misuse based on the patient/resident risk profile.

Placement of dispensers at unsupervised building entrances and in unsupervised public and outpatient areas is not recommended.