FIRE CODE BULLETIN
December 2004
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Fire Safety and Hand Hygiene in Healthcare Facilities
ISSUE:
This bulletin covers alcohol based hand hygiene products used in healthcare facilities. It discusses
safety concerns and requirements of the Alberta Fire Code, Alberta Building Code, Occupational
Health & Safety Act and Code and the National Fire Protection Association (NFPA) Life Safety
Code.
BACKGROUND:
Regulatory officials are concerned about the potential fire and occupational safety hazards
associated with the storage and use of products that contain 60% or greater alcohol concentration
(ethanol). The product is available in an alcohol rinse, gel or foam and is a Class IB flammable
liquid. The Alberta Fire Code defines a Class 1B flammable liquid as having a flash point below
22.8°C and a boiling point at or above 37.8°C. Flash point information on products should be
readily available from Material Safety Data Sheets (MSDS).
Health Canada, Alberta Health and Wellness, Centre for Disease Control and Prevention and the
Joint Commission on Accreditation of Healthcare Organizations are implementing policies that
require healthcare workers to use alcohol based hand hygiene products in hospitals and other
health care settings. The policies are resulting in the installation of alcohol based hand hygiene
products in patient rooms and corridors of healthcare facilities. In addition, the NFPA Life Safety
Code committee have developed technical amendments to permit the safe use of these products.
Regulatory authorities and healthcare facility operators need to be aware of requirements in the
Alberta Fire Code, Alberta Building Code, Occupational Health and Safety Act and NFPA Life
Safety Code on how alcohol based hand hygiene products are regulated.
Alberta Workplace Health & Safety has a major role related to worker safety under the Alberta
Occupational Health and Safety Act.
ISSUE OF THIS INFORMATION BULLETIN IS
AUTHORIZED BY THE ADMINISTRATOR.
C.M. TYE
Alberta Municipal Affairs, 16th Floor, Commerce Place, 10155 – 102 Street, Edmonton, Alberta, Canada, T5J 4L4
Safety Codes Council, Suite 800, 10707 – 100 Avenue, Edmonton, Alberta, Canada, T5J 3M1
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CODE REQUIREMENTS:
Alberta Fire Code 1997
Part 4 of the Alberta Fire Code regulates the storage and handling of flammable liquids and
combustible liquids in Care facilities. The emerging health care practice of using alcohol based
hand hygiene products in patient rooms and corridors has never been contemplated in the Code.
For this reason the NFPA Life Safety Code has been amended to accommodate the use of these
products. The National and Alberta Fire Codes permit the use of alcohol based hand hygiene
products under general rules that are substantially different from the NFPA Life Safety Code.
The Canadian Codes have not been updated in the same way as the NFPA Life Safety Code to
specifically address these products.
Clause 4.2.1.1.(2)(d) Exempts flammable liquid pharmaceutical products used in closed
containers having a capacity of not more than 5 L.
4.2.6.3. Maximum Quantities
1) Except as provided in Sentence (2), the storage of flammable liquids and combustible liquids
outside of a cabinet or room required in Article 4.2.6.2. is permitted, provided such storage does
not exceed
a) 10 L, including not more than 5 L of Class I liquid, in a single room, or
b) 250 L, including not more than 60 L of Class II liquid, or 10 L of Class I liquid, in a
single fire compartment having at least a 45 min fire separation.
4.2.10.2. Maximum Quantity per Cabinet
1) The maximum quantity of flammable liquids and combustible liquids stored in a cabinet shall
be 500 L, of which not more than 250 L shall be Class I liquids.
4.2.10.3. Maximum Quantity per Fire Compartment
3) In care occupancies, the total quantity of flammable liquids and combustible liquids stored in
cabinets in a single fire compartment shall not exceed the quantity permitted for one cabinet.
Articles 4.2.6.3., 4.2.10.2. and 4.2.10.3. Specify the quantities of flammable liquids permitted in
rooms and fire compartments of health care facilities.
Section 2.8 Emergency Planning. Provides facility operators with guidance in developing and
implementing a fire safety plan that should include the control of fire hazards that may be
presented by alcohol based hand hygiene products. The safety plan must address the storage,
use, dispensing and disposal of flammable liquid containers.
Alberta Building Code 1997
The Alberta Building Code affects the use of alcohol based hand hygiene products when the
containers are mounted in care facility corridors. Sentence 3.3.1.9.(3) limits an object located
within 1980 mm of the floor to not project more than 100 mm horizontally into the corridor.
Containers that project more than 100 mm must be recessed or located in a manner that does not
obstruct a barrier-free path of travel where the object may create a hazard to a visually impaired
person traveling adjacent to the wall.
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Alberta Occupational Health & Safety (OHS) Legislation
The Alberta OHS legislation consists of the OHS Act, OHS Regulation and the OHS Code.
Where a worker may be exposed to a harmful substance, as defined in the OHS Regulation,
Section 15 of the Regulation requires an employer to:
• Establish procedures to minimize worker exposure
• Provide training on these procedures to workers
• Ensure that workers apply the training they receive
Part 4 of the OHS Code establishes the detailed requirements for chemical hazards at the work
site where workers may be exposed to a harmful substance. These include the following:
• A worker may not be exposed to a substance in excess of its Occupational Exposure
Limit
• Where a worker may be exposed to a substance during a single work shift that exceeds 8
hours, the Occupational Exposure Limit must be adjusted
• Worker exposure must be assessed, and workers must be informed of the hazards of
exposure
• Workers may not eat, drink or smoke in an area of the work site contaminated by a
harmful substance
• Harmful substances must be properly labelled and stored
Part 10 of the OHS Code requires an employer to establish safety procedures for the use and
handling of flammable liquids. Procedures must address:
• Preventing accidental ignition of flammable products used at the work site
• Preventing flammable products from creating a flammable atmosphere
• Safe storage and disposal of containers
• Control of ignition sources including smoking materials
NFPA Life Safety Code
Tentative Interim Agreement (TIA 03-6) contains additional information specific to the NFPA
Life Safety Code. The TIA is not reproduced in whole, instead the following extracts are used to
supplement the Alberta Fire Code and make a workable safe condition for facility operators:
• Dispensers in corridors cannot exceed 1.2 L capacity
• Dispensers in suites or patient rooms cannot exceed 2 L capacity
• Dispensers must be located a minimum of 1.2 m apart from each other
• The dispensers shall not be installed over or directly adjacent to an ignition source
• Maximum additional storage in a smoke compartment is 18.9 L (5 gal) greater quantities
must be stored in conformance with NFPA 30, “Flammable and Combustible Liquids
Code.”
RECOMMENDATIONS:
Flammable liquid storage requirements prescribed by the Alberta Fire Code do not specifically
address the current needs for using alcohol based hand hygiene products in health care facilities.
By combining the various requirements of the Alberta Building Code (ABC), Alberta Fire Code
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(AFC), NFPA Life Safety Code (LSC) and Occupational Health & Safety Code (OHS), a general
safe operating guideline can be established.
The LSC requirements are considered good practices and can be used to supplement the AFC
requirements where the Code lacks specific clarity. Operators in hospitals and other health care
settings implementing policies for the use of alcohol hand hygiene products should consider
incorporating the following fire prevention and occupational safety measures:
1.
2.
3.
4.
5.
6.
Dispensers in corridors cannot exceed 1.2 L capacity. (LSC)
Dispensers in suites or patient rooms cannot exceed 2 L capacity. (LSC)
Dispensers be located a minimum of 1.2 m apart from each other. (LSC)
Dispensers are not to be installed over or directly adjacent to an ignition source. (LSC)
Dispensers cannot project more than 100 mm into a corridor from the wall. (ABC)
Maximum amount of 10 L flammable liquid can be located in corridors within a single
fire compartment having at least a 45-minute fire separation. (AFC)
7. Maximum additional 20 L may be stored in a 45 min. rated storage room within a single
fire rated compartment. (LSC)
8. Address the control of fire hazards in the building fire safety plan. (AFC)
9. Develop appropriate safety procedures and training for workers that includes: (OHS)
a. Information on product health effects
b. Procedures preventing accidental ignition
c. Warnings about ignition sources
d. Emergency procedures in the event of contamination or ignition
e. Proper labelling and placards for hazardous substances
Inquiries for additional information can be directed to the following Government resources:
Alberta Municipal Affairs – Safety Services
1-866-421-6929 or http://www.municipalaffairs.gov.ab.ca
Alberta Workplace Health & Safety
1-866-415-8690 or http://www.worksafely.org