Infection Control Today - 01/2004: ic community

Industry Responds to Alcohol-Based Handrub Controversy

Editors note: Representatives from various manufacturers of alcohol-based handrubs share their perspective on the current confusion and controversy generated by the placement of hand-hygiene product dispensers in hospital hallways and the flammability issues raised by fire safety officials. To read last months update on this issue, log on to:

Reader Feedback

By Tina Brooks

Q: Should workers be allowed to launder uniforms and scrubs at home?

A: From the scientific evidence I have seen, as long as uniforms are laundered daily it really does not matter where they are cleaned.
Pam Higdem, RN, BSN, CIC Little Rock, Ark.

A: I say why not? We pay laundrys huge money contracts, and we get less than quality results.
Parie D. Reynolds, MSgt, USAF, CRST NCOIC, Operating Room Services Flight Lackland AFB, Texas

A: We have been laundering our own scrubs for approximately two years and have not noted an increase in surgical site infections. Our policy regarding soiled scrubs is that if they are grossly soiled they are sent to the hospital laundry in a plastic bag for laundering and the laundry returns to the department. This has worked well for the staff and anesthesia; the surgeons and others are a different story, but theyve gotten used to it. We get an occasional grumble, but nothing too severe. We have decreased the number of lost and missing scrubs. The staff are able to bring in their own scrubs to wear rather than the ones provided by the hospital. I have to say that it has worked very well for us.
Linda Chase Clinical Director Holy Cross Hospital Taos, N.M.

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STERIS Corporation

By Elizabeth Park and Michael Ebers

According to the Centers for Disease Control and Prevention (CDC), more than 2.4 million patients nationwide acquire nosocomial infections annually. Several changes in handhygiene recommendations have been made by the CDC in an attempt to change this trend, including the publication of the HICPAC Guideline for Hand Hygiene in Healthcare Settings in 2002.

The published literature reports several factors that affect hand hygiene, such as inadequate access to a sink, lack of soap and paper towels, and lack of knowledge of guidelines/protocols.1 One approach to improving overall hand hygiene has been to increase access to hand hygiene products by placing fast-acting alcohol products, including gels and foams, in convenient locations throughout hospital facilities. In particular, dispensers placed in hallways outside of patient rooms have addressed the lack of access to sinks, soap, and water.

Although the benefits of increased access to alcohol sanitizer products are apparent, questions about the risk of placement in egress hallways have recently emerged. In order to address these questions, STERIS provided support to the American Society for Healthcare Engineering (ASHE) of the American Hospital Association for a risk-modeling study to determine the potential risk of placing and storing alcohol products in egress hallways. ASHE concluded in its recent study, Alcohol Based Hand Rub Solution Fire Modeling Analysis Report, that single containers installed in an egress corridor should not exceed a maximum capacity of 1.2 liters for alcohol-based handrub solutions in gel/liquid form. Single containers installed in a suite should not exceed a maximum capacity of 2 liters for alcohol-based handrub solutions in gel or liquid form.2 The modeling scenario used by ASHE identified the maximum capacities allowable and clarified the potential risk with placement of alcohol-containing dispensers.

Recently, questions have also been asked about the safe use of foamed alcohol products. The National Fire Protection Association (NFPA) publishes consensus codes intended to minimize the possibility of fire that are widely used as a basis for regulation at all levels of government. The NFPA 30B Code for the Manufacture and Storage of Aerosol Products provides guidance on aerosol products based upon a classification system established through experimentation with aerosols under actual fire conditions.

NFPA 30B classifies Alcare and Alcare Plus as Level 1 aerosols. Level 1 is the least hazardous classification for flammability. Provided that dispensers are mounted in hallways so that they do not pose an obstruction hazard, the regulations and standards set no specific limitations placed on the storage or dispensing of Level 1 aerosols in institutional facilities.

ASHE has also committed to amending the report to address pressurized alcohols. History suggests that the incidence of fires in healthcare facilities is low and that the positive effect of increasing accessibility to hand hygiene products is significant in reducing the risk of nosocomial infections. Years of peer-reviewed, epidemiologic studies confirm the importance of a time-saving, easy-to-use means of decontaminating hands.

STERIS Corporation strongly supports the findings made by ASHE and actively encourages research initiatives that provide guidance on the safest and most effective uses of alcohol handrinses and gels. Elizabeth Park is product manager and Michael Ebers is regulatory manager at STERIS Corporation.


1. Guideline for Hand Hygiene in Healthcare Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Oct. 25, 2003; page 25.

2. Alcohol-based Hand Rub Solution fire Modeling Analysis Report; American Society for Healthcare Engineering of the American Hospital Association, Aug. 22, 2003.

Ecolab, Inc.

By Kirsten M. Thompson

As a manufacturer of several alcohol handrub products and a sponsor of the AHA/ASHE study, we appreciate the attention given to the issue of flammability of alcohol-based handrubs and the placement of dispensers in the December 2003 issue of ICT.

Based on the guidelines from the AHA/ASHE study, we recommend a proactive approach to the installation of alcohol-based handrubs by encouraging customers to utilize the following checklist:

  1. Determine that the alcohol-based handrub products to be routinely used and located in a patient hallway do not exceed the 1.2 liter capacity; likewise, products in patient rooms do not exceed 2 liters.
  2. Do not install dispensers over electrical outlets or near other sources of ignition. Document any dispensers in the facilitys fire plan that project more than 3.5 inches into the corridor.
  3. Identify that the proper storage equipment is in place to include flammable liquid storage cabinets on patient floors, and that quantities in these cabinets do not exceed that of the local fire code.
  4. Be aware of the proper handling, storage and disposition of the alcohol-based handrubs, and contact local fire authorities for specific disposal instructions of product containers that may have product in them.
  5. Document that the local fire marshal or fire-code enforcement official has reviewed the use of the alcohol product in the area, such as outside a patient room, and has provided an approval letter both for the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and the hospital records.
  6. When providing an in-service to healthcare workers, emphasize the need to allow the hands to dry completely after use to eliminate the potential for ignition. Instruct healthcare workers on the proper cleanup procedure for the product from a spill or misapplication.

In addition, we want to hear about enforcement situations as they develop to help avoid unnecessary removal of waterless alcohol handrubs after installation.

As a leading manufacturer of alcohol-based handrubs, we are working with the key stakeholders to seek a reasonable solution for the use of these products based on good science, balancing fire safety concerns with infection control interests. The ASHE recommendations report is a good start for moving the discussion forward but the varied interests involved with this issue will have to work cooperatively while attempting to minimize the disruption of infection control procedures in the interim.

In terms of the next steps to be taken, AHA/ASHE is committed to working with the NFPA to bring about changes in the national fire codes and will be drafting a tentative interim amendment that may get approved by the NFPA Fall Education Conference in Reno, Nev. as this article is submitted for publication in late November. The AHA is planning to focus its resources on the code makers first, followed by the code enforcers (e.g., CMS, JCAHO, etc.).

From our perspective as a manufacturer, there are two points that deserve further discussion and potential follow up as part of the AHA/ASHE study:

  1. While liquid/gel alcoholic solutions are most commonly used, the aerosol pressurized foam products have become increasingly popular in recent years. We have become aware of some specific enforcement problems relating to these products and we expect objections to their use generally to be raised by fire service enforcement. As a consequence, we believe that some level of analysis and testing should be included as part of this study, something we strongly recommended. As a legitimate component of the waterless handrub family, a similar fire modeling for this product also needs to be addressed.
  2. The most prevalent use of alcohol-based handrub products has been in hospital and medical settings, but we see an increased use for them in other settings including food service, food processing, schools and virtually anywhere microbial contamination could be deemed a problem. Outbreaks relating to specific organisms, such as the recent SARS threat, highlight the interest in these products relating to high volume transportation nodes.

Being able to balance varying needs will allow us to do our part to provide the best product to our customers while satisfying the concerns of the fire protection agencies.

Kirsten M. Thompson is a technical service expert in the Healthcare Professional Products Division of Ecolab, Inc.

Thatcher Pharmaceutical Company

By Clint Bodily

We appreciate ICTs willingness to help healthcare professionals clarify some of the confusion and variation of opinion as to the potential flammability risk of alcohol hand sanitizer products.

Thatcher Pharmaceutical Company manufactures a 64 percent ethyl alcohol-based hand sanitizer called GelSan, and as a result of the widespread concern over flammability risks, we have been helping to educate our customers about this issue for some time now.

Over the past several years, our company has worked closely with healthcare facilities who use our product, and we have found that there is a huge variation of opinion as to where alcohol gel dispensers should or should not be allowed and how much volume those dispensers should contain. We have spoken with many different organizations and contacts, ranging from the NFPA to the Occupational Safety and Health Administration (OSHA), to localized fire marshals, and found that regulations vary from state to state, and sometimes even from county to county and facility to facility.

Since there is no universal specification regarding the flammability issue, our company has encouraged healthcare facilities to base their decisions on the information that has been documented from reliable studies and statistics, and communicated to the public from sources such as the CDC, the Society for Healthcare Epidemiology of America, Inc. (SHEA) and the Association for Professionals in Infection Control and Epidemiology (APIC). These organizations have posted articles and reliable information on this subject. While it is our personal opinion that dispensers would be most effective in hallways, we do not want to conflict with any state or local fire regulations so our company routinely recommends that hospitals place our GelSan dispensers inside of patient rooms as a general rule.

It has been our policy to encourage each facility to work closely with its local fire marshal. Because of the fact that some fire marshals have allowed dispensers in corridors, and others have not, we feel it is important for each individual hospital to state its position to the local fire marshal and vice-versa. If a particular fire marshal will allow dispensers in hallways; that is a plus. If a fire marshal will not allow dispensers in hallways, then a facility should respect and comply with that regulation. Either way, it is beneficial for hospitals and fire marshals to be talking to one another. We feel that this process will greatly help to clarify misconceptions about the potential flammability risk of alcohol-based handrubs and lead to future specifications that will be more universal for everyone.

As a manufacturer, we provide constructive feedback to our customers on the exact placement of dispensers inside of the patient rooms, and help facilities to avoid common mistakes such as hanging dispensers above power outlets or light switches, etc. We also encourage infection control nurses to create a protocol for their facility that is based on CDC guidelines and instructs hospital staff on when to use our product, when to wash with soap and water, and teaches the importance of performing proper hand hygiene. Such protocols should include specific safety instructions for dispenser mounting and proper storage of replacement gel packets, and instruct workers to let alcohol gel dry on their hands before touching metal doors or any hospital equipment that could potentially cause a spark. If a hospital creates a protocol that instructs healthcare workers how to correctly use and store alcohol handrub products, many of the concerns with flammability risk will be safely addressed.

As a matter of opinion only, we feel that the benefits of using alcohol handrubs in hospitals far outweigh the potential flammability risks. If alcohol-based products are stored away from open flames, sparks, or extreme temperatures, they are generally very safe and stable substances. Our company provides safe handling and storage instructions on our Material Safety Data Sheet (MSDS), which tells our customers how to properly handle and use our product. The number of hospital acquired infections our nation faces today seems to be a much greater threat to patient safety than the remote risk of a fire resulting from the use of alcohol-based handrubs.

We commend the ongoing efforts of the CDC, APIC, JCAHO, the NFPA, and all state and local fire marshals who are addressing this issue. We look forward to the day when clarified specifications are agreed upon so that alcohol handrub products can be effectively used to help reduce the spread of infections in medical facilities everywhere.

Clint Bodily is with Thatcher Pharmaceutical Company.

3M Health Care Services

By Gayle D. Peters

The benefits offered by alcohol-based hand antiseptics are significant to healthcare professionals and patients. It is widely recognized that improved hand hygiene is a key factor in reducing the risk of healthcare associated infections which directly cause or contribute to an estimated 80,000 deaths annually and cost the U.S. healthcare system $4.5 billion.

3M was pleased to support the American Society for Healthcare Engineering (ASHE) fire-modeling study to acquire information that facilitates agreement concerning placement of dispensers to promote proper hand hygiene. Education about proper use of products is important in all areas of the healthcare continuum.

Gayle D. Peters is with 3M Health Care Services.

Coloplast Corp.

By Randy Barranger

The article titled, Flammability of Alcohol Hand Hygiene Products: Extinguishing the Flames of Controversy was a well-done piece summarizing the issues surrounding alcohol-based hand hygiene products. As one of the manufacturers that co-sponsored the fire modeling study, Coloplast applauds the cooperation that has been shown between the manufacturers, AHA, ASHE, CDC, NFPA, APIC and other organizations, to address an unresolved controversy on the placement of the alcohol-based hand rub dispensers.

The alcohol-based handrub products have been shown to be a highly effective tool for health care professionals to use in the challenge of nosocomial infections. We hope that fire marshals throughout the U.S. will adopt the guidelines developed from the ASHE firemodeling study and modify local fire codes to allow healthcare facilities to place the alcohol handwash dispensers in locations that will encourage their use. Whether in the hallways or inside patient rooms, the easy access to alcohol handwash products is one of the keys to increasing adherence to hand-hygiene protocols. Considering the eight to 20 opportunities for hand hygiene per patient hour, there are many opportunities for hand hygiene during patient care, so if dispensers are outside patient rooms, personal carriage of the product is also important as a complement to the dispenser usage.

The collaboration and conclusion on these flammability issues is quite timely, as JCAHO has announced the 2004 National Patient Safety Goals and most recently their revised Infection Control Standards for 2005. ... Reducing the risk of nosocomial infections must become a top priority for hospitals and other healthcare organizations, to quote Richard Croteau, MD, JCAHOs executive director of strategic initiatives.

Randy Barranger is vice president of commercial development for Coloplast Corp.


1. Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health Care Setting: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002:51 (No. RR-16, 20,24).

Executive Summary: Alcohol-Based Handrub Solution Fire-Modeling Analysis Report
(Released Aug. 22, 2003 by the American Society for Healthcare Engineering)

Note: Because of the flammable nature of alcohol-based hand rubs, the installation of dispensers and the storage of products should be discussed with the local fire marshal and/or local building officials to address compliance with prevailing building and fire codes. Organizations are encouraged to utilize this fire modeling study to inform the discussion and arrive at a solution that meets the dual goals of effective hand hygiene and fire safety.

Alcohol-based products are more effective for standard hand hygiene or hand antisepsis by healthcare personnel than soap or antimicrobial-containing soap products. For optimal effectiveness, both the type and concentration of alcohol in the handrub are important variables. Two of the more common formulations of alcohol-based handrubs used in the U.S. are equal to or greater than 60 percent of ethyl alcohol or isopropyl alcohol by volume. Alcohol is a flammable liquid. Local building and fire codes regulate the storage and use of flammable liquids. The use of alcoholbased handrubs therefore may present a fire hazard within healthcare facilities. This, combined with the increasing prevalence in use of alcoholbased handrubs as part of overall hand hygiene programs in U.S. health care facilities, necessitates careful analysis to assure the spectrum of safe care of patients mitigates both healthcare-associated infections (HAI) and facility-associated fires.

The American Society for Healthcare Engineering (ASHE) of the American Hospital Association commissioned a study of how these handrubs will react to a fire in a typical patient care environment. The report documents a computerized fire-modeling study conducted for typical installations of dispensers containing alcohol-based handrubs. This study includes modeling fire scenarios to capture a reasonable range of potential fire scenarios to analyze the overall level of hazard presented by the hand-hygiene solution.

The study results indicate that installing handrub dispensers is acceptable in both corridor and suite location. The results also showed the spacing of dispensers at or near each patient room entrance not to be a significant risk for additional ignition and involvement of more than one dispenser. Based on these results, ASHE recommends the following for the use and storage of the alcohol-based hand rub solutions:

  • Single containers installed in an egress corridor should not exceed a maximum capacity of 1.2 liters for alcohol-based handrub solutions in gel/liquid form. Single containers installed in a suite should not exceed a maximum capacity of 2 liters for alcohol-base hand-rub solutions in gel/liquid form.
  • Dispensers should not be installed over electrical receptacles or near other potential sources of ignition.
  • Dispensers that project more than 3.5 inches (4.5 inches if the 2003 Edition of the Life Safety Code is adopted) into the corridors should be noted in the facilitys Fire Plan and Training Program.
  • All storage of replacement alcohol-based handrub containers on patient floors, regardless of the quantity, should be within an approved flammable liquid storage cabinet.
  • The quantity of replacement alcohol-based handrub containers stored and used on any floor, including bulk storage in central supply rooms, should not exceed the maximum quantity permitted by the local prevailing building and fire codes.

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