February 2014 Alberta Fire Code Page 1 of 5. Fire Safety and Hand Hygiene in Healthcare Facilities

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1 FIRE CODE VARIANCE February 2014 Alberta Fire Code Page 1 of 5 ISSUE: Fire Safety and Hand Hygiene in Healthcare Facilities This Variance 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 and Safety Act and Code and the National Fire Protection Association (NFPA) Life Safety Code. Studies have shown that if certain conditions are met, the fire hazard created by these products is greatly reduced while there can be a significant benefit in reducing acquired infections. Infection control is an important part of current health care practices. 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, corridors and throughout 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 and Safety has a major role related to worker safety under the Alberta Occupational Health and Safety Act. CODE REQUIREMENTS: 1 Alberta Fire Code 2006 Part 4 of the Alberta Fire Code regulates the storage and handling of flammable liquids and combustible liquids in Care facilities. Issue of this STANDATA is authorized by the Chief Fire Administrator [Original Signed] Kevan D. Jess Alberta Municipal Affairs Safety Services, 16th Floor, Street, Edmonton, Alberta, Canada, T5J 4L4 Safety Codes Council, 1000, Jasper Avenue, Edmonton, Alberta, Canada, T5J 3S9

2 The health care practice of using alcohol based hand hygiene products in health care facilities has never been contemplated in the Code and is now a standard of clinical care as per international, national and provincial practice guidelines. 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 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 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 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 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 , and 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 2006 The Alberta Building Code affects the use of alcohol based hand hygiene products when the containers are mounted in care facility corridors. Sentence (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. Alberta Occupational Health and 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 Page 2 of 5

3 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 for 8 hours (adjusted if the shift is longer than 8 hours) or the ceiling limit at any time. Where a worker may be exposed to a harmful substance the exposure is kept as low as reasonably achievable Worker exposure must be assessed, and workers must be informed of the health hazards of exposure, trained in procedures to minimize exposure and understands the procedures 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 and take precautionary measures 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 Note: The term smoke compartment in the following text equates with the term fire compartment in the Alberta Fire and Building Codes Smoke Compartment A space within a building that is enclosed by smoke barriers on all sides including the top and bottom. Fire compartment means an enclosed space in a building that is separated from all other parts of the building by enclosing construction providing a fire separation having a required fireresistance rating.(afc). NFPA excerpt on: Alcohol-Based Hand-Rub Dispensers Best Practice requirements for use of Alcohol-Based Hand-Rub Dispensers in new and existing health care facilities; Where dispensers are installed in a corridor, the corridor shall have a minimum width of 6ft (1830 mm) The maximum individual dispenser fluid capacity shall be as follows gal (1.2 L) for dispensers in rooms, corridors and areas open to corridors gal (2.0 L) for dispensers in suites of room Dispensers shall be separated from each other by a horizontal spacing of not less than 48 in (1220 mm) Not more than an aggregate 10 gal (37.8 L) of alcohol-based hand-rub solution shall be in use outside of a storage cabinet in a single smoke compartment. Page 3 of 5

4 The addition of one dispenser per room shall not be included in the aggregate maximum of 10 gal (37.8 L) per single smoke compartment. Storage of quantities greater than 5 gal (18.9 L) in a single smoke compartment shall meet the storage requirements of the Alberta Fire Code. Dispensers shall not be installed in the following locations: - Above an ignition source within 1 in (25 mm) horizontal distance from each side of the ignition source. - To the side of an ignition source within 1 in (25 mm) horizontal distance from each side of the ignition source. - Beneath an ignition source within 1 in (25 mm) vertical distance from the ignition source. Dispensers installed directly over carpeted areas shall be permitted only in sprinkler protected smoke compartments. The alcohol-based hand-rub solution shall not exceed 95 percent alcohol content by volume. Operation of the dispenser shall comply with the following criteria: - The dispenser shall not release its contents except when the dispenser is activated, either manually or automatically by touch-free activation. - Any activation of the dispenser shall occur only when an object is placed within 4 in (100 mm) of the sensing device. - An object placed within the activation zone and left in place shall not cause more than one activation. - The dispenser shall not dispense more solution than the amount required for hand hygiene consistent with the label instructions. - The dispenser shall be designed, constructed and operated in a manner that ensures that accidental or malicious activation of the dispensing device is minimized. The dispenser shall be tested in accordance with the manufacture s care and use instructions each time a new refill is installed VARIANCE: 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 (AFC), NFPA Life Safety Code (LSC) and Occupational Health & Safety Code (OHS), a general safe operating guideline can be established and adopted as a Variance under the Alberta Fire Code 2006 as per Article of Division C. The NFPA 101 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 may consider incorporating the following fire prevention and occupational safety measures: 1. This Variance only applies in fully sprinklered healthcare facilities. 2. Dispensers in corridors cannot exceed 1.2 L capacity. (LSC) 3. Dispensers in suites of patient rooms cannot exceed 2 L capacity. (LSC) 4. Dispensers be located a minimum of 1.2 m apart from each other. (LSC) 5. Operation of the dispensers shall meet the requirements outlined in the LSC. Page 4 of 5

5 6. Dispensers are not to be installed over or directly adjacent to an ignition source. (LSC) 7. Dispensers are not to be installed over carpeted areas. (LSC) 8. Dispensers cannot project more than 100 mm into a corridor from the wall. (ABC) 9. Maximum amount of 10 L flammable liquid can be located in corridors within a single fire compartment having at least a 45 min. fire separation. (AFC) 10. Not more than an aggregate 40 L of alcohol-based hand-rub solution shall be in use outside of a storage cabinet in a single fire compartment. 11. Maximum additional 40 L may be stored in a 45 min. rated storage room within a single fire compartment. (LSC) 12. Address the control of fire hazards in the building fire safety plan. (AFC) 13. 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 or Alberta Workplace Health & Safety or This Variance applies throughout the Province of Alberta 1 All references are to the Alberta Fire Code, Division B, unless otherwise stated. Page 5 of 5