Public Safety Services

             GOVERNOR										                                                   STATE FIRE MARSHAL


I N T E R P R E T I V E M E M O R A N D U M 2 0 0 5 – 1


To:          Licensed Architects

                Licensed Engineers

                Louisiana Nursing Home Association

                Louisiana Hospital Association

                Health Care Section Louisiana Department of Health and Hospitals/Health Standards Section


From:     Pat Day Rainey,

               Supervisor Health Care Section


Approved by:   Henry Fry, Acting State Fire Marshal

                         Don Zeringue, Chief Architect


Date:     Effective May 25, 2005


Re:    Alcohol Based Hand Rub Solutions in Health Care Facilities (ABHR)


This policy is intended to provide guidance on the placement of Alcohol-Based Hand Rub Solutions (ABHR) dispensers in facilities under the jurisdiction of the Louisiana Office of the State Fire Marshal (OSFM), and the proper storage of quantities of this product. This policy supercedes Interpretive Memorandum 2003 – 1.


This policy applies to all Hospitals, long-term care facilities (LTC), religious non-medical health care institutions (RNHCI) , in-patient hospices, programs of all-inclusive care for the elderly (PACE), intermediate care for the mentally retarded (ICF/MR), critical access hospitals (CAH) and ambulatory surgical centers (ASC).


The following is the policy of this office:





---0.3 gallons (1.2 liters) for dispensers in rooms, corridors, and areas open to corridors.

---0.5 gallons (2.0 liters) for dispensers in suites of rooms.

















Commonly asked questions relative to OSFM Interpretive Memorandum 2005 – 1, Alcohol Based Hand Rub Solutions (ABHR) in Health Care Facilities:


  1. Are ABHR containers allowed on medical carts in the corridor?


  1. Yes, a (1) personal-sized portable container is allowed on the med. cart during the distribution of meds. After distribution of meds is complete and the med. cart is not in-use, the med. cart shall be properly stored. A mountable dispenser is not allowed to be permanently affixed to the med. cart due to the potential of the cart being stored in an alcove in the corridor system.


  1. Are ABHR containers allowed at the nurses' station?


  1. Yes, a (1) personal-sized container is allowed to be carried on a person. Containers are carried in pockets, on lanyards, etc.


Q.   Are ABHR containers allowed in the dining room?


A.   If your dining room has substantial doors that resist the passage of smoke and have positive latching hardware, so that in the event of a fire the door can be closed to contain the spread of fire and smoke and separate the dining room from the corridor, containers may be located in this area.


Q.   Are ABHR containers allowed in patient rooms?


A.   Yes, ABHR containers are allowed in patient rooms because all patient sleeping rooms are required to have substantial doors that resist the passage of smoke and have positive latching hardware which separates the room from the corridor.


Q.   Will the requirement for ABHR not to be installed directly over carpeted surfaces except in sprinklered smoke compartments apply facility wide or only in direct-patient care areas?


A.   No, this would apply facility wide, even in existing non-sprinklered facilities.


Q.   Pediatrics is not listed as a most vulnerable population, but are they included in that category? They are certainly most vulnerable in spreading germs.


A.   The recommendations did not specifically define pediatrics, however, each facility will be able to define additional types of patients as vulnerable populations if they choose to.


Q.   In cases where the manufacturer has provided no preventive maintenance recommendation, would a facility policy outlining review by staff through daily use and subsequent documentation of replacement of malfunctioning dispensers serve to meet the intent of this recommendation? Are there any issues with facilities utilizing single use disposable dispensers (i.e. non-refillable pump containers)?


  1. Each facility will be required to provide a reasonable maintenance schedule to be included in the facility policy and procedure manual. This maintenance schedule shall be time specific, will be required to be documented and the documentation available for any inspectors to review during the inspection process. Examples: Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Centers for Medicare/Medicaid Services (CMS), Office of State Fire Marshal.


Q.   If a parallel is drawn between the small pressurized cans of ABHR and larger gas cylinders used in healthcare, would securing the plastic holders with a screw be an acceptable parallel to chaining the large gas cylinder? This is asked because the chains used to secure medical gas cylinders are screwed into the wall.


A.   No, at the present time, our office does not support pressurized containers of ABHR, especially in exit access corridors.