Public Safety Services
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
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:
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)?
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.