The CDC may have tripped the momentum of its own call for a switch to alcohol-based hand sanitizers in healthcare - with two paragraphs on page 13 of its highly touted, 50-page Guidelines for Hand Hygiene in Health-Care Settings that mentions that the alcohol-based gels, foams and liquids are hazardous materials.

Some states' fire authorities are restricting the placement of the handwash dispensers and the amount of stock on hand. In the event of a fire, they say, such alcohol-based rubs in dispensers could be veritable hand grenades attached to walls, fueling a fire and preventing safe escapes, especially if the rubs are stored in exit hallways.

Here's advice on balancing fire-safety laws with hand-hygiene science. Keep in mind that in the absence of scientific data about the risk of fire associated with dispensers of alcohol-based hand products, the benefits of prevention of infections in patients and workers clearly outweighs the risk.

The risk is real
Alcohol-based rubs usually contain about 60 percent alcohol (sometimes more) and have a flashpoint range of about 69 to 75' F. Flashpoint is the temperature at which, given the proper conditions, vapors from alcohol rubs can ignite. Such rubs fall into the category of Class I flammable liquid (flashpoint below 100' F). The lower a substance's flashpoint, the more likely it will vaporize and thus potentially cause a fire.

In one case cited by the CDC and published in the June 2002 American Journal of Infection Control, a healthcare worker suffered first-degree burns on her hand after static electricity sparked unevaporated alcohol rub, causing a flash fire.

Laws vs. science
The 2000 National Fire Protection Association (NFPA) 101 (Life Safety Code) prohibits installing items such as alcohol-based hand-sanitizing gel and foam dispensers in exit corridors unless they protrude no more than 3.5 inches into an exit corridor and are also mounted at or below a height of 38 inches. Those specs set the dispenser far below hand level, potentially negating strides toward better hand-washing compliance.

The fire-hazard problem could open the market to low-alcohol, nonflammable products, which are not strong enough to decontaminate the hands. The CDC recommends an alcohol content of at least 60 percent for effective hand hygiene, but some of the nonflammable products have only 10 percent alcohol.

NFPA 101 Sec.8.4.3.2 states: "No storage or handling of flammable liquids or gases shall be permitted in any location where such storage (or use of product) would jeopardize egress from the structure" NFPA 101-19.7.5.4 prohibits placing combustible decorations in any healthcare occupancy unless they are flame retardant.

JCAHO's position
The Joint Commission on Accreditation of Healthcare Organization's (JCAHO) committee on healthcare safety recently met to determine the organization's position on the placement and use of alcohol-based foam and gel dispensers in corridors. JCAHO realizes none of the codes precisely addresses alcohol gel and foam dispensers, but believes it's a good bet for your facility to comply with the guidelines regarding storing combustible items found in 101-19.7.5.4.

"Our contention is that the typical alcohol gel and foam dispensers used in the healthcare setting are of such limited size and volume that the alcohol gels' contribution to the hazard of acceleration of fire development or fire spread is negligible," says Thomas S. Vanderhoof, an Environment of Care Fellow on the JCAHO Standards Interpretation Group.

The American Society for Healthcare Engineering (ASHE) of the American Hospital Association (AHA) has commissioned a nationally known fire-engineering firm to test heat and hot-gas development and associated hazards from alcohol-based hand-hygiene solutions. Many fire scenarios will be modeled to capture a reasonable range of the risks presented. This study is under way, and results are expected later this month. With the results, the infection-control and fire-safety communities will be better equipped to balance potentially increased fire risk with improved patient outcomes and hand hygiene.

What to do for now
In the meantime, William M. Wagner, ScD, a senior consultant for Safety Management Services, Inc., in Atlanta offers these suggestions:

• Determine the appropriate quantity of material to be routinely used and where it should be located. The dispensers should be mounted in an area with adequate ventilation - usually determined by your engineering consultant.
• Identify the process used to order these hazardous materials, outlining the steps taken and criteria used to assess that the material will be handled, stored and disposed of in the proper manner.
• Document that the local fire marshal or fire-code enforcing official has reviewed the use of the flammable material in the desired area and provided an "approval" letter for the JCAHO and your records.
• Identify the storage equipment used for any standby supply; the CDC requires that this be a flammable storage cabinet.
• Identify the disposal process for spent containers, especially foam cans containing an aerosol propellant.
• Instruct healthcare workers on proper use of the gels and foams (hands must be rubbed together until alcohol has evaporated, for example) to prevent spontaneous ignition of the residues on the hands.
• Instruct healthcare workers on the proper clean-up procedure for the product from a spill or misapplication.

Balancing act
The goal now is to balance improved hand-hygiene practices with proper fire-safety compliance. Until the results of ASHE's study are released and subsequent recommendations are made, the preceding outlines the steps for dealing with this issue that should satisfy the CDC and fire-safety regulators.