The My ASHE Messenger column contains excerpts of topics from My ASHE, the member-only community for the American Society for Healthcare Engineering.

QUESTION: What is the maximum amount of alcohol hand sanitizer and alcohol disinfectant allowed to be stored?

Life Safety Code (LSC) 2012 18/19.3.2.6(7) limits the amount of alcohol-based hand rub stored in a smoke compartment to 5 gallons. Storage in excess of 5 gallons in a smoke compartment must be stored in accordance with NFPA 30, which may require a flammable liquid storage cabinet depending on the amount stored.

QUESTION: How should managers deal with discrepancies between the Facility Guidelines Institute/ASHRAE guidelines and Association for Advancement of Medical Instrumentation standards regarding humidity and temperature requirements for central sterile supply decontamination spaces?

As directed in the Interim Guidance from the Joint HVAC Task Force from September 2015, every health care organization should determine the HVAC operating parameters for operating rooms (ORs), the sterile processing department, endoscope procedure rooms, sterile storage rooms and other monitored areas that meet their patient, personnel and product storage needs. Pulling together a multidisciplinary team to review the current HVAC operating practice and perform a risk assessment of the affected area(s) is a good first step. The team should enter the values/parameters they will follow on a day-to-day basis into their organization’s HVAC system policy, along with corrective measures to mitigate risk and restore the HVAC system to the desired parameters when conditions fall outside of those values. The interim guidance at www.ashe.org/hvac has more information.

QUESTION: During a fire drill, it was noted that there are no strobes in our off-site ambulatory surgery center’s four ORs. Can someone reference whether they are a requirement or not?

LSC 2102 9.6.3.5.3 exempts existing fire alarm systems from requirements for visible devices.

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