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Dialysis Water Training Class Dialysis Water Training Class Dialysis Water Training Class Dialysis Water Training

Class
J im Curtis, CHT J im Curtis, CHT
J im Curtis & Associates, LLC J im Curtis & Associates, LLC
Water Basics Water Basics Water Basics Water Basics
Water is the Universal Solvent Water is the Universal Solvent Water is the Universal Solvent Water is the Universal Solvent
It will change almost anything it comes in It will change almost anything it comes in
contact with contact with contact with contact with
It will It will Be Be changed by almost anything in changed by almost anything in
touches touches touches touches
Water affects EVERY dialysis treatment Water affects EVERY dialysis treatment
Water Basics Water Basics Water Basics Water Basics
There are Four primary categories of There are Four primary categories of There are Four primary categories of There are Four primary categories of
contaminates found in Water contaminates found in Water
Particulate Particulate Particulate Particulate
Inorganics Inorganics
Organics Organics Organics Organics
Microbiological Microbiological
Water Basics Water Basics Water Basics Water Basics
Particulate Matter Includes: Particulate Matter Includes: Particulate Matter Includes: Particulate Matter Includes:
S di t S di t Sediment Sediment
Suspended Solids Suspended Solids
GG Grit Grit
Sand Sand
Water Basics Water Basics Water Basics Water Basics
Inorganic Material is the Ionic Inorganic Material is the Ionic Inorganic Material is the Ionic Inorganic Material is the Ionic
Concentration found in water Concentration found in water
Dissolved Salts Dissolved Salts Dissolved Salts Dissolved Salts
Other dissolved solids Other dissolved solids
Hardness Hardness Hardness Hardness
Common Inorganic material found in water Common Inorganic material found in water
Calcium, Magnesium, Sodium, Potassium, Calcium, Magnesium, Sodium, Potassium,
Zinc, Nitrates, Lead, Copper, Aluminum, etc. Zinc, Nitrates, Lead, Copper, Aluminum, etc.
Water Basics Water Basics Water Basics Water Basics
Organic Material often come in more Organic Material often come in more Organic Material often come in more Organic Material often come in more
complex chemical compounds. complex chemical compounds.
Examples include chloramines pesticides Examples include chloramines pesticides Examples include chloramines, pesticides, Examples include chloramines, pesticides,
insecticides, tannins insecticides, tannins
C b lt f ith t l C b lt f ith t l Can be a result of either natural or man Can be a result of either natural or man- -
made causes. made causes.
Water Basics Water Basics Water Basics Water Basics
Microbiological Contaminates include: Microbiological Contaminates include: Microbiological Contaminates include: Microbiological Contaminates include:
Bacteria and Bacterial Endotoxin Bacteria and Bacterial Endotoxin
Viruses Viruses Viruses Viruses
Cysts Cysts
Protozoan's Protozoan's
These substances vary greatly in size and These substances vary greatly in size and
shape shape pp
Different problems are encountered with Different problems are encountered with
each each
Water Terms You Should Know Water Terms You Should Know Water Terms You Should Know Water Terms You Should Know
Source Water: Source Water: Where the water originally Where the water originally Source Water: Source Water: Where the water originally Where the water originally
comes from. Generally the two sources are comes from. Generally the two sources are
Ground Water that comes from wells, and Ground Water that comes from wells, and ,,
Surface Water which comes from lakes and Surface Water which comes from lakes and
rivers. rivers.
Feed Water: Feed Water: This is the water “feeding” your This is the water “feeding” your
treatment system, and is often treated by the treatment system, and is often treated by the
municipality before it gets to you. municipality before it gets to you.
Water Terms You Should Know Water Terms You Should Know Water Terms You Should Know Water Terms You Should Know
Pre Pre--Treatment: Treatment: These are the devices that These are the devices that Pre Pre Treatment: Treatment: These are the devices that These are the devices that
you yse to treat the water prior to the Reverse you yse to treat the water prior to the Reverse
Osmosis or DI device. Osmosis or DI device.
Reverse Osmosis: Reverse Osmosis: This is a process where This is a process where
hydraulic pressure is used to overcome the hydraulic pressure is used to overcome the
osmotic pressure and cause water to move from osmotic pressure and cause water to move from osmotic pressure and cause water to move from osmotic pressure and cause water to move from
areas of high solute concentration to areas of areas of high solute concentration to areas of
Low solute concentration. Low solute concentration.
Permeate: Permeate: Water that has passed through the Water that has passed through the
RO membrane RO membrane-- “Product” water “Product” water
Water Terms You Should Know Water Terms You Should Know Water Terms You Should Know Water Terms You Should Know
Concentrate: Concentrate: This is the waste water fromthe This is the waste water fromthe Concentrate: Concentrate: This is the waste water from the This is the waste water from the
RO, which now has a higher concentration of RO, which now has a higher concentration of
solutes that the feed water did. solutes that the feed water did.
Filtration (or Depth Filtration): Filtration (or Depth Filtration): Removal of Removal of
suspended particles by mechanically trapping suspended particles by mechanically trapping
themin a filter media themin a filter media them in a filter media. them in a filter media.
Submicron Filtration: Removing particles less Submicron Filtration: Removing particles less
than 1 micron in size. than 1 micron in size. than 1 micron in size. than 1 micron in size.
Ultrafiltration: Removing particles from .002 to Ultrafiltration: Removing particles from .002 to
.1 microns. .1 microns.
Water Terms You Should Know Water Terms You Should Know Water Terms You Should Know Water Terms You Should Know
Ion Exchange: Ion Exchange: Exchange of one ionic particle for Exchange of one ionic particle for Ion Exchange: Ion Exchange: Exchange of one ionic particle for Exchange of one ionic particle for
another another
Cation: Positively Charged particle Cation: Positively Charged particle
Anion: Negatively charged particle Anion: Negatively charged particle
Deionization: Removal of charged particles from Deionization: Removal of charged particles from
t b f i h t b f i h water by means of ion exchange. water by means of ion exchange.
Chloramines: Chloramines: Chemical used to disinfect Chemical used to disinfect
i i l t li Th f d b i i l t li Th f d b municipal water supplies. They are formed by municipal water supplies. They are formed by
combining chlorine and ammonia. combining chlorine and ammonia.
Water Terms You Should Know Water Terms You Should Know Water Terms You Should Know Water Terms You Should Know
Hardness: Refers to the sumof calcium Hardness: Refers to the sumof calcium Hardness: Refers to the sum of calcium Hardness: Refers to the sum of calcium
and magnesium in the water and magnesium in the water
Expresses in Grains per Gallon of Calcium Expresses in Grains per Gallon of Calcium Expresses in Grains per Gallon of Calcium Expresses in Grains per Gallon of Calcium
Carbonate (1 GPG = 17.1 mEq/L) Carbonate (1 GPG = 17.1 mEq/L)
Primary source of scaling that fouls RO Primary source of scaling that fouls RO Primary source of scaling that fouls RO Primary source of scaling that fouls RO
membranes. membranes.
Water Terms You Should Know Water Terms You Should Know Water Terms You Should Know Water Terms You Should Know
pH: Potential of Hydrogen pH: Potential of Hydrogen pH: Potential of Hydrogen pH: Potential of Hydrogen
Q tit ti t f th idit Q tit ti t f th idit Quantitative measurement of the acidity or Quantitative measurement of the acidity or
alkalinity on a logarithmic scale from 1 to alkalinity on a logarithmic scale from 1 to
14 14 14 14
pH > 7 = Alkaline (base) pH > 7 = Alkaline (base)
pH = 7 = Neutral pH = 7 = Neutral
pH < 7 = Acidic pH < 7 = Acidic
Water Terms You Should Know Water Terms You Should Know Water Terms You Should Know Water Terms You Should Know
Microorganism: Small living organisms Microorganism: Small living organisms Microorganism: Small living organisms Microorganism: Small living organisms
such as Bacteria, Virus or Ptotozoan. such as Bacteria, Virus or Ptotozoan.
Colony Forming Units (CFU): The Colony Forming Units (CFU): The Colony Forming Units (CFU): The Colony Forming Units (CFU): The
measurement of viable colonies of measurement of viable colonies of
bacteria in a culture sample bacteria in a culture sample pp
Biofilm: A gelatinous material secreted by Biofilm: A gelatinous material secreted by
certain bacteria that can adhere to the certain bacteria that can adhere to the
walls of piping and forms a protective walls of piping and forms a protective
coating coating
Water Terms You Should Know Water Terms You Should Know Water Terms You Should Know Water Terms You Should Know
Endotoxin: A lipopolysaccoride that is part Endotoxin: A lipopolysaccoride that is part Endotoxin: A lipopolysaccoride that is part Endotoxin: A lipopolysaccoride that is part
of cell walls of gram negative bacteria of cell walls of gram negative bacteria
LAL: Limulus Amebocyte Lysate a test for LAL: Limulus Amebocyte Lysate a test for LAL: Limulus Amebocyte Lysate, a test for LAL: Limulus Amebocyte Lysate, a test for
bacterial endotoxin derived from intestinal bacterial endotoxin derived from intestinal
fluid of horseshoe crabs fluid of horseshoe crabs fluid of horseshoe crabs. fluid of horseshoe crabs.
Endotoxin Units (EU): Quantitative Endotoxin Units (EU): Quantitative
t f th t f E d t i t f th t f E d t i measurement of the amount of Endotoxin measurement of the amount of Endotoxin
contamination in a solution. contamination in a solution.
Importance of Monitoring Importance of Monitoring Importance of Monitoring Importance of Monitoring
Increases Patient Safety Increases Patient Safety Increases Patient Safety Increases Patient Safety
Maintain Regulatory Compliance Maintain Regulatory Compliance
A P F ti i f W t A P F ti i f W t Assures Proper Functioning of Water Assures Proper Functioning of Water
Treatment System Treatment System
Water for Hemodialysis is a Water for Hemodialysis is a
Prescription Prescription
More than 95%of the dialysate is water More than 95%of the dialysate is water More than 95% of the dialysate is water More than 95% of the dialysate is water
The Doctor makes the ultimate decision The Doctor makes the ultimate decision
regarding water quality??? regarding water quality??? regarding water quality??? regarding water quality???
Water treatment systems for dialysis Water treatment systems for dialysis
id d Cl II id d Cl II purposes are considered a Class II purposes are considered a Class II
Medical Device by the FDA Medical Device by the FDA
Exposure to Water and Exposure to Water and
Contaminants Contaminants
Average Population Average Population Hemodialysis Patients Hemodialysis Patients Average Population Average Population
Drinks approximately Drinks approximately
14 L/week (2 L/day) 14 L/week (2 L/day)
Hemodialysis Patients Hemodialysis Patients
Exposed to Exposed to
approximately 360 L/ approximately 360 L/
Able to excrete toxic Able to excrete toxic
substances in urine substances in urine
week (120 week (120
L/treatment) L/treatment)
Kidneys unable to Kidneys unable to
substances in urine substances in urine
Contaminants Contaminants
Kidneys unable to Kidneys unable to
excrete toxic excrete toxic
substances substances
Contaminants Contaminants
selectively absorbed in selectively absorbed in
GI system, indirectly GI system, indirectly
exposed to blood exposed to blood
Contaminants directly Contaminants directly
exposed to blood via exposed to blood via
dialyzer membrane dialyzer membrane
exposed to blood exposed to blood
dialyzer membrane dialyzer membrane
Weekly Water Exposure Weekly Water Exposure Weekly Water Exposure Weekly Water Exposure
W t S t W t S t Water System Water System
Components Components Components Components
Dust Dust Dust Dust
Dust Dust Dust Dust
Gases Gases Gases Gases
Impurities Impurities Impurities Impurities
Pumping Station
Lake, Stream, Pond
River Minerals
Minerals & Impurities
River
Well
Water
Table
Minerals
Impurities
Hardness
Minerals & Impurities
Minerals
Surface Surface
GroundWater
Water Water
Ground Water
Higher in organic Higher in organic
material, silt, and material, silt, and
bacterial levels bacterial levels
Higher in inorganic Higher in inorganic
material and lower in material and lower in
organic material organic material
bacterial levels bacterial levels
Industrial wastes, Industrial wastes,
automotive by automotive by--products, products,
organic material organic material
Calcium, magnesium, Calcium, magnesium,
iron, zinc, copper, iron, zinc, copper,
di l i di l i
yy p , p ,
run off or dumping run off or dumping
Rural area water is also Rural area water is also
ff t d b i l ff t d b i l
sodium, aluminum sodium, aluminum
Any mineral the water Any mineral the water
comes in contact with comes in contact with
affected by animal affected by animal
wastes, fertilizers and wastes, fertilizers and
pesticides pesticides
will change it. will change it.
Level of mineral may be Level of mineral may be
specific to an area specific to an area spec c to a a ea spec c to a a ea
Municipal System Municipal System Municipal System Municipal System
Treats available water to meet the Nation Drinking Water Standards. Treats available water to meet the Nation Drinking Water Standards.
Quality of municipal water dictates what is needed as pretreatment Quality of municipal water dictates what is needed as pretreatment y p p y p p
for the RO system. for the RO system.
Communication with water supplier (name, phone number, Communication with water supplier (name, phone number,
lt t t t) lt t t t) alternate contact) alternate contact)
Get annual water reports and updates sent to you Get annual water reports and updates sent to you
Can have high chlorine/chloramine levels (minimum of .1 Can have high chlorine/chloramine levels (minimum of .1
PPM) PPM) PPM) PPM)
High pH (8.5 and higher with chloramine is problem) High pH (8.5 and higher with chloramine is problem)
High fluoride levels or spikes High fluoride levels or spikes
O d i l d i l fl l t O d i l d i l fl l t Overdosing or normal dosing polymers or flocculent can Overdosing or normal dosing polymers or flocculent can
cause membrane problems cause membrane problems
Alum (aluminum sulfate) is commonly used Alum (aluminum sulfate) is commonly used
Water quality can change after natural disasters Water quality can change after natural disasters Water quality can change after natural disasters Water quality can change after natural disasters
Emergency (disaster) or temporary water supplies Emergency (disaster) or temporary water supplies
Complete System Complete System Complete System Complete System
Complete System Complete System Complete System Complete System
BackflowPreventers BackflowPreventers Backflow Preventers Backflow Preventers
Temperature Temperature
Blending Valves Blending Valves
Feed Water
gg
Feed Water Booster Feed Water Booster
Pumps Pumps pp
Bladder Tanks Bladder Tanks
Electrical Outlets Electrical Outlets ect ca Outets ect ca Outets
Backflow c ow
Preventer
BackflowPreventer BackflowPreventer Backflow Preventer Backflow Preventer
Prevents reverse flow of Prevents reverse flow of
water and or contaminants water and or contaminants water and or contaminants water and or contaminants
through the valve, which through the valve, which
would contaminate the would contaminate the would contaminate the would contaminate the
potable drinking water potable drinking water
l l supply. supply.
Installed, tested by licensed Installed, tested by licensed sta ed, tested by ce sed sta ed, tested by ce sed
plumber plumber
Monitoring the Monitoring the
B kfl P i D i B kfl P i D i Backflow Prevention Device Backflow Prevention Device
Monitor: Pressure Monitor: Pressure
Drop across the Drop across the pp
device device
Look For: A change of Look For: A change of gg
10 PSI from baseline 10 PSI from baseline
Temperature Blending Valve Temperature Blending Valve Temperature Blending Valve Temperature Blending Valve
Increases the incoming Increases the incoming gg
water temperature to water temperature to
approximately 77 approximately 77
degrees F, “ ideal” degrees F, “ ideal” g , g ,
membrane operating membrane operating
temperature. temperature.
Membrane product Membrane product
Discharge Discharge
Membrane product Membrane product
water production is water production is
based in part on water based in part on water
temperature temperature temperature. temperature.
Production decreases Production decreases
1.5% per F, 3% per C. 1.5% per F, 3% per C.
Hot Water Hot Water
Cold Water Cold Water Cold Water Cold Water
Temperature Blending Valve Temperature Blending Valve Temperature Blending Valve Temperature Blending Valve
Considerations/Concerns Considerations/Concerns Considerations/Concerns Considerations/Concerns
Pipe size of valve normally small Pipe size of valve normally small
High pressure losses through valve is High pressure losses through valve is High pressure losses through valve is High pressure losses through valve is
normal (20 normal (20 - - 45 PSI) 45 PSI)
Inlet screens can get clogged Inlet screens can get clogged
Personnel adjusting valve too hot or cold Personnel adjusting valve too hot or cold
Monitoring the Monitoring the
T Bl di V l T Bl di V l Temperature Blending Valve Temperature Blending Valve
Monitor: Temperature Monitor: Temperature Monitor: Temperature Monitor: Temperature
on a Daily Basis post on a Daily Basis post
blending valve blending valve
Look For: Appropriate Look For: Appropriate
water temperature, water temperature,
minimal temperature minimal temperature
fluxuation fluxuation
Booster Booster
Pumps Pumps
Booster Pumps Booster Pumps Booster Pumps Booster Pumps
Used to increase and maintain Used to increase and maintain
feed water pressure to a feed water pressure to a feed water pressure to a feed water pressure to a
desired level for system desired level for system
operation operation operation operation
Booster Pumps Booster Pumps Booster Pumps Booster Pumps
Considerations/Concerns Considerations/Concerns Considerations/Concerns Considerations/Concerns
Does not make water, only boosts available water Does not make water, only boosts available water
pressure pressure pp
Pump sizing considerations: flows and pressures Pump sizing considerations: flows and pressures
needed for equipment, supplied pressure, pipe needed for equipment, supplied pressure, pipe
i l t i l d i l t i l d size, electrical needs. size, electrical needs.
Intermittent low pressure problems Intermittent low pressure problems
Pump operation is controlled by a pressure Pump operation is controlled by a pressure Pump operation is controlled by a pressure Pump operation is controlled by a pressure
switch switch
Tend to be noisy Tend to be noisy
Booster Pump Monitoring Booster Pump Monitoring Booster Pump Monitoring Booster Pump Monitoring
Maintains Adequate Maintains Adequate Maintains Adequate Maintains Adequate
water flow and water flow and
pressure pressure
Monitor: Water Monitor: Water
Pressure Pressure
Look For: Pump Look For: Pump
turning on and off at turning on and off at
i i appropriate pressures appropriate pressures
Bladder Tank Bladder Tank Bladder Tank Bladder Tank
Provides additional Provides additional
volume of water for volume of water for
Air Bladder or
Diaphragm
changing flow changing flow
requirements requirements requirements requirements
To PT & RO
Bladder Tank Bladder Tank Bladder Tank Bladder Tank
Concerns/Considerations Concerns/Considerations Concerns/Considerations Concerns/Considerations
Normally installed with booster pump as Normally installed with booster pump as
buffer buffer buffer buffer
Can be used without a pump Can be used without a pump
Bacteria problems if used with non Bacteria problems if used with non-- Bacteria problems if used with non Bacteria problems if used with non--
chlorinated water chlorinated water
Loss of air charge Loss of air charge Loss of air charge Loss of air charge
Never use post RO unit Never use post RO unit
It is a large dead end and will trap disinfectants It is a large dead end and will trap disinfectants It is a large dead end and will trap disinfectants It is a large dead end and will trap disinfectants
with no way to ensure a negative level with no way to ensure a negative level
Bladder Tank Bladder Tank Bladder Tank Bladder Tank
Monitoring Monitoring Monitoring Monitoring
Pump turns on and off at preset Pump turns on and off at preset
pressures pressures
Complete System Complete System Complete System Complete System
Pretreatment
Chemical Feed Chemical Feed
Pumps Pumps
M lti M lti M di Filt M di Filt Multi Multi--Media Filters Media Filters
Softener Tanks Softener Tanks
Carbon Tanks Carbon Tanks
Chemical Feed Pumps/ Chemical Feed Pumps/ pH Control pH Control Chemical Feed Pumps/ Chemical Feed Pumps/ pH Control pH Control
Used to adjust pH Used to adjust pH Used to adjust pH Used to adjust pH
to a desired level to a desired level
by metering in by metering in
Pump
by metering in by metering in
small amounts of small amounts of
chemical into chemical into chemical into chemical into
feed water. feed water.
Acid tank
Chemical Feed Pumps/ Chemical Feed Pumps/ pH Control pH Control Chemical Feed Pumps/ Chemical Feed Pumps/ pH Control pH Control
Concerns/Considerations Concerns/Considerations Concerns/Considerations Concerns/Considerations
Municipalities increasing pH to comply Municipalities increasing pH to comply
with lead and copper rule with lead and copper rule with lead and copper rule with lead and copper rule
Commonly used acids are Hydrochloric Commonly used acids are Hydrochloric
(HCL)(Muriatic) and Sulfuric (H2SO4) (HCL)(Muriatic) and Sulfuric (H2SO4) ( )( ) ( ) ( )( ) ( )
Settings need to be monitored Settings need to be monitored
Automatic controls and monitors can Automatic controls and monitors can
get out of calibration get out of calibration
Can lose prime on acid line to pump Can lose prime on acid line to pump
All f h f i d d f All f h f i d d f All of the safety precautions needed for All of the safety precautions needed for
chemicals chemicals
Acid Feed Pump Monitoring Acid Feed Pump Monitoring Acid Feed Pump Monitoring Acid Feed Pump Monitoring
Monitor: pH post feed Monitor: pH post feed Monitor: pH post feed Monitor: pH post feed
pump pump
Look For: pH should Look For: pH should pp
be between 7.0 and be between 7.0 and
8.0 8.0
Multi Multi--media (Depth) Filters media (Depth) Filters Multi Multi media (Depth) Filters media (Depth) Filters
Used to filter out
particulates 10 microns
and larger by depth
filtration
Contains multiple Contains multiple
layers of various layers of various
sized rocks and sized rocks and
sand sand
Multi Multi- -media Filters media Filters
Multiple layers of various sized Multiple layers of various sized p y p y
gravel, sand, anthracite gravel, sand, anthracite
-- selected for specific density selected for specific density
-- re re--stratifies after back wash stratifies after back wash
ends ends
Water pressure/flow must be Water pressure/flow must be
adequate to backwash properly adequate to backwash properly adequate to backwash properly adequate to backwash properly
-- HIGH flow requirement HIGH flow requirement
Multi Multi- -media Filters, cont. media Filters, cont. ,,
Media bed can become overloaded & unable Media bed can become overloaded & unable
to backwash to backwash
Sized in Sized in--flow rate ( gallons) per square foot flow rate ( gallons) per square foot
of cross of cross--sectional area sectional area
T t ith Silt D it I d (SDI) kit T t ith Silt D it I d (SDI) kit Test with Silt Density Index (SDI) kit Test with Silt Density Index (SDI) kit
-- measures ‘plugging’ rate measures ‘plugging’ rate
Multi Multi--Media Filter Monitoring Media Filter Monitoring
Monitor: Pressure Monitor: Pressure Monitor: Pressure Monitor: Pressure
drop across the drop across the
device device
Look For: A change of Look For: A change of
10 PSI or more from 10 PSI or more from
baseline baseline
Softeners & Exchange Tanks Softeners & Exchange Tanks
For the
removal of
water
hardness
(calcium,
magnesium)
in exchange
for sodium
NaCl
solution
Cation Exchange Process
Na+
Na+
Na+
Na+
Softener
R i B d
Ca++ Ca+ Ca++ Ca++
2Na+
Na+
Na+
Resin Bead
Cl- Cl-
2Na+
2Na+
2Na+
Na+
Na+
N +
Na+ 2Na+
2Na+
2Na+ Na+
Na+
Cl- Cl-
2Na+
Softener Considerations and Softener Considerations and
CCConcerns Concerns
Rated in grains of hardness removal Rated in grains of hardness removal
capacity capacity
30,000 or 30K grain is 1 cu. ft. of resin. 30,000 or 30K grain is 1 cu. ft. of resin.
15 Lbs. of salt saturated water needed 15 Lbs. of salt saturated water needed
to completely recharge 30K or 1 cu. ft. to completely recharge 30K or 1 cu. ft.
Softener Resin Softener Resin
Iron fouling of resin effects exchange Iron fouling of resin effects exchange
ff performance performance
Chlorine exposure damages resin Chlorine exposure damages resin
A f i (di i i h d ti ) A f i (di i i h d ti ) Age of resin (diminished regeneration) Age of resin (diminished regeneration)
Softeners Concerns and Softeners Concerns and
Considerations (cont.) Considerations (cont.)
Dirt in salt clogs brine valve Dirt in salt clogs brine valve Dirt in salt clogs brine valve Dirt in salt clogs brine valve
Salt bridge can form in brine tank Salt bridge can form in brine tank
Testing incorrectly Testing incorrectly Testing incorrectly Testing incorrectly
Potassium chloride not recommended Potassium chloride not recommended
to regenerate softeners used for to regenerate softeners used for to regenerate softeners used for to regenerate softeners used for
Dialysis Dialysis
Water Softener Water Softener Water Softener Water Softener
Monitor: Monitor:
Post softener hardness, Post softener hardness,
amount of salt in the brine amount of salt in the brine
tank, tank,
“salt bridge” in the brine “salt bridge” in the brine
tank, tank,
pressure drop across the pressure drop across the
d i d i device, device,
settings on regeneration settings on regeneration
timer. timer.
Water Softener slide 2 Water Softener slide 2 Water Softener slide 2 Water Softener slide 2
Look For: Look For: Look For: Look For:
Hardness not Hardness not
exceeding 10 PPM exceeding 10 PPM
Adequate amount of Adequate amount of
salt with no salt bridge salt with no salt bridge
Pressure drop change Pressure drop change Pressure drop change Pressure drop change
from baseline of 10 from baseline of 10
PSI or more PSI or more
Timer set to activate Timer set to activate
when facility is not in when facility is not in
operation operation operation operation
Carbon Tanks Carbon Tanks Carbon Tanks Carbon Tanks
Used to
remove remove
chlorine and
chloramines chloramines
harmful to RO
membranes membranes
and patients
Carbon Tanks Carbon Tanks Carbon Tanks Carbon Tanks
Carbon commonly referred to as GAC (Granular
A i d C b ) Activated Carbon)
Made from organic materials exposed to high
temperatures temperatures
Bituminous coal, peach pits, coconut shells
Extremely porous
1 teaspoon of GAC has the surface area of football
field.
M h i f 12 40 i ll Mesh size of 12 x 40 microns or smaller
Iodine number of 900 or higher
Acid washing removes manufacturing debris Acid washing removes manufacturing debris
Carbon Tanks Carbon Tanks Carbon Tanks Carbon Tanks
Tanks are sized for Empty Bed Contact Time
(EBCT).
10 minutes EBCT required by AAMI standards
Two tanks in series for total EBCT, worker and
polisher, each with an EBCT of 5 minutes
Chlorine testing is done from a sample port after
the first tank, and before the second
Carbon Tank Concerns Carbon Tank Concerns Carbon Tank Concerns Carbon Tank Concerns
High levels of chlorine and chloramines can shorten the life of High levels of chlorine and chloramines can shorten the life of
carbon
Color blind tester
Automatic testing equipment is available
Bacteria growth will happen in and after carbon
Channeling or compaction of bed
Bypass valves on carbon tanks are a hazard
T ti h ld t t k l th 15 i t f Testing should not take place sooner than 15 minutes from
startup, and at the end of the tank fill cycle in an indirect
system
Carbon Tank Monitoring Carbon Tank Monitoring Carbon Tank Monitoring Carbon Tank Monitoring
Monitor: Monitor: Monitor: Monitor:
Chlorine and Chlorine and
chloramine levels after chloramine levels after
the worker tank before the worker tank before
each patient shift each patient shift
pressure drop across pressure drop across pressure drop across pressure drop across
each tank each tank
Back Back- -flush timer flush timer
EBCT calculated and EBCT calculated and
at least 10 minutes for at least 10 minutes for
both tanks both tanks both tanks both tanks
Carbon Tanks slide 2 Carbon Tanks slide 2 Carbon Tanks slide 2 Carbon Tanks slide 2
Look for: Look for: Look for: Look for:
Chlorine levels within Chlorine levels within
AAMI standards (0.5 AAMI standards (0.5
PPM free chlorine, 0.1 PPM free chlorine, 0.1
PPM chloramine) PPM chloramine)
Pressure drop change Pressure drop change Pressure drop change Pressure drop change
of 10 PSI or greater of 10 PSI or greater
Back Back- -flush timer set to flush timer set to
activate when facility is activate when facility is
not in operation. not in operation.
Chlorine Test Chlorine Test Chlorine Test Chlorine Test
Test for Test for
“Free chlorine” “Free chlorine”
“Total chlorine” “Total chlorine”
Diff b “f hl i ” d “ l Diff b “f hl i ” d “ l Difference between “free chlorine” and “total Difference between “free chlorine” and “total
chlorine” equals the chloramine level chlorine” equals the chloramine level
Always test for “total chlorine”and never “free Always test for “total chlorine”and never “free Always test for total chlorine and never free Always test for total chlorine and never free
chlorine” alone chlorine” alone
Perform on fresh water Perform on fresh water after fifteen minutes after fifteen minutes
Test Between Working Tank and Polisher Test Between Working Tank and Polisher
Chlorine Test Chlorine Test Chlorine Test Chlorine Test
Allowable Limits: Allowable Limits:
Free FreeChlorine 0 5 ppm Chlorine 0 5 ppm Free FreeChlorine 0.5 ppm Chlorine 0.5 ppm
Chloramines 0.1 ppm Chloramines 0.1 ppm
Use Accurate Measurement Tools Use Accurate Measurement Tools Use Accurate Measurement Tools Use Accurate Measurement Tools
DPD Testing Method DPD Testing Method
Chlorine Specific Test Strips Chlorine Specific Test Strips Chlorine Specific Test Strips Chlorine Specific Test Strips
Prefilters Prefilters Prefilters Prefilters
Final Barrier Final Barrier Final Barrier Final Barrier
against particles against particles
or debris that or debris that
Head
Flow Flow
or debris that or debris that
can damage RO can damage RO
pumps and pumps and
Outlet
O-ring
pumps and pumps and
membranes membranes
Filter
C t id Cartridge
Shell
Prefilters Prefilters Prefilters Prefilters
Considerations/Concerns Considerations/Concerns Considerations/Concerns Considerations/Concerns
Disposable cartridge with a 1 micron filter Disposable cartridge with a 1 micron filter
size size size size
Change prefilter when Change prefilter when
88--10 PSI higher than clean pressure loss 10 PSI higher than clean pressure loss 88 10 PSI higher than clean pressure loss 10 PSI higher than clean pressure loss
Or on a routine schedule Or on a routine schedule
Disinfect bowl and head to remove biofilm Disinfect bowl and head to remove biofilm
AAMI standards require housing to be AAMI standards require housing to be
opaque to prevent algae growth opaque to prevent algae growth
Complete System Complete System Complete System Complete System
OO
RO Unit
RO Pumps RO Pumps
Membranes Membranes
Disinfection Disinfection
RO Unit
Disinfection Disinfection
Gauges and Flow Gauges and Flow
meters meters
Monitors and Controls Monitors and Controls
RO Pumps RO Pumps RO Pumps RO Pumps
B t f d B t f d Boosts feed Boosts feed
water up to water up to
membrane membrane
Outlet Outlet
membrane membrane
operating operating
pressures pressures
Vent Vent
Housing Housing
Pump Pump
pressures pressures
Motor Motor
Inlet Inlet
RO Pumps RO Pumps RO Pumps RO Pumps
Two common types of pumps Two common types of pumps Two common types of pumps Two common types of pumps
Rotary vane positive displacement Rotary vane positive displacement
multi multi--stage centrifugal stage centrifugal multi multi stage centrifugal stage centrifugal
Considerations/concerns Considerations/concerns
Operated without adequate water supply, run dry, or Operated without adequate water supply, run dry, or p q pp y y p q pp y y
grit in water is damaging to pumps grit in water is damaging to pumps
Material of construction is important Material of construction is important
Stainless steel and inert plastics Stainless steel and inert plastics Stainless steel and inert plastics Stainless steel and inert plastics
Some motors are noisy Some motors are noisy
Spiral Wound Membrane Spiral Wound Membrane
Element Element
Permeate Flow Permeate Flow
Concentrate Concentrate
Permeate Permeate
Feed Feed Feed
Solution
Feed
Solution
Collection Tube Collection Tube
RO Membrane Section RO Membrane Section RO Membrane Section RO Membrane Section
Outer
RO Membrane
Inner Mesh
Outer
Mesh
Outer Mesh Outer Mesh Outer Mesh Outer Mesh
Outer Membrane at 10X Outer Membrane at 10X Outer Membrane at 10X Outer Membrane at 10X
Inner Membrane at 200X Inner Membrane at 200X
(Torn edge) (Torn edge)
Inner Mesh at 60X Inner Mesh at 60X Inner Mesh at 60X Inner Mesh at 60X
Inner Mesh at 200X Inner Mesh at 200X Inner Mesh at 200X Inner Mesh at 200X
Spiral Wound Membrane Spiral Wound Membrane
Element Element
The heart of water treatment process The heart of water treatment process
Will remove on an average 96 Will remove on an average 96--99% of all incoming 99% of all incoming Will remove on an average 96 Will remove on an average 96--99% of all incoming 99% of all incoming
solute. This includes dissolved inorganic, large solute. This includes dissolved inorganic, large
organic (>200 molecular weight), endotoxins, viruses, organic (>200 molecular weight), endotoxins, viruses,
and bacteria and bacteria and bacteria and bacteria
Thin Film Composite (TFC) and Cellulose acetate Thin Film Composite (TFC) and Cellulose acetate
(CA) are most commonly used membranes in dialysis (CA) are most commonly used membranes in dialysis
today today
Service life is 1 to 5 years or greater Service life is 1 to 5 years or greater
Monitoring Reverse Osmosis Monitoring Reverse Osmosis
Device Device (Operating Parameters) (Operating Parameters)
Monitor: Water Monitor: Water
pressure and flow at pressure and flow at pp
various locations various locations
throughout the throughout the
system. system.
Monitoring RO Device slide 2 Monitoring RO Device slide 2
(Operating parameters) (Operating parameters)
Look For: Changes in Look For: Changes in
the water pressure the water pressure pp
and flow at various and flow at various
locations throughout locations throughout
the system. the system.
RO Water Quality Monitoring 1 RO Water Quality Monitoring 1 RO Water Quality Monitoring 1 RO Water Quality Monitoring 1
Monitor Chemical Analysis Monitor Chemical Analysis Monitor Chemical Analysis Monitor Chemical Analysis
of Raw and RO Product of Raw and RO Product
water; Compare Results to water; Compare Results to
AAMI Standards. Must be AAMI Standards. Must be
Analyzed Annually Analyzed Annually
(Q t l R d d) (Q t l R d d) (Quarterly Recommended) (Quarterly Recommended)
RO Water Quality Monitoring 2 RO Water Quality Monitoring 2 RO Water Quality Monitoring 2 RO Water Quality Monitoring 2
Continuous Monitoring by Continuous Monitoring by Continuous Monitoring by Continuous Monitoring by
Indirect Method Required Indirect Method Required
Percent Rejection and/or Percent Rejection and/or j j
TDS Monitor TDS Monitor
Alarm Set to Divert to Alarm Set to Divert to
Drain if Quality Below Drain if Quality Below
Standards. Standards.
RO Water Quality Monitoring 3 RO Water Quality Monitoring 3 RO Water Quality Monitoring 3 RO Water Quality Monitoring 3
Conductivity Is Measured Conductivity Is Measured Conductivity Is Measured Conductivity Is Measured
Both Pre and Post RO Both Pre and Post RO
Membrane Membrane
Is An Indication Of Total Is An Indication Of Total
Dissolved Solids In Water Dissolved Solids In Water
Percent Rejection Is Percent Rejection Is
Calculated From Pre and Post Calculated From Pre and Post
C d i i M C d i i M Conductivity Measurements Conductivity Measurements
{(Input {(Input--Product)/Input}*100 = % Product)/Input}*100 = %
Rejection Rejection Rejection Rejection
Complete System Complete System Complete System Complete System
Storage Tanks and Storage Tanks and
Delivery
Storage Tanks and Storage Tanks and
Pumps Pumps
DI Tanks and Monitors DI Tanks and Monitors
Delivery
UV Lamps UV Lamps
Ultra Filters and Ultra Filters and
Submicron Filters Submicron Filters Submicron Filters Submicron Filters
Drains Drains
Piping Loops Piping Loops
Storage Tank Storage Tank Storage Tank Storage Tank
Collects and Collects and
recirculates RO recirculates RO
water to meet peak water to meet peak
usage demands usage demands gg
Storage Tanks Storage Tanks Storage Tanks Storage Tanks
Shape and design of tank is important Shape and design of tank is important p g p p g p
Conical shaped bottom, completely sealed, spray Conical shaped bottom, completely sealed, spray
heads, vent filter, and check valve overflows heads, vent filter, and check valve overflows
3 0 Ft / l it t k d d t t 3 0 Ft / l it t k d d t t 3.0 Ft./sec. velocity at peak demand at return 3.0 Ft./sec. velocity at peak demand at return
loop loop
Volume of tank needs to be small enough Volume of tank needs to be small enough not not Volume of tank needs to be small enough Volume of tank needs to be small enough not not
to allow water to stand dormant to allow water to stand dormant
Level controls start and stop RO unit Level controls start and stop RO unit pp
Bacteria growth in a storage tank can Bacteria growth in a storage tank can
happen happen
Frequent bacteria/LAL testing recommended Frequent bacteria/LAL testing recommended
Deionization (DI) Tank Deionization (DI) Tank Deionization (DI) Tank Deionization (DI) Tank
Removes Removes
positively and positively and p y p y
negatively negatively
charged ions charged ions gg
from the water from the water
DI Tank Monitors DI Tank Monitors DI Tank Monitors DI Tank Monitors
Measures Resistivity to indicate DI water quality Measures Resistivity to indicate DI water quality
Must be temperature compensated with audible and Must be temperature compensated with audible and
visual alarms after last tank visual alarms after last tank
Single light monitors can be used on all tanks before last Single light monitors can be used on all tanks before last
tank tank
<1 meg <1 meg- -ohm/cm resistivity ohm/cm resistivity
Power failure situations Power failure situations
water continues to flow through DI and is not monitored water continues to flow through DI and is not monitored
Connect to generator back Connect to generator back--up up
Safest Set Safest Set--up for DI up for DI Safest Set Safest Set up for DI up for DI
Two tanks in a series Two tanks in a series Two tanks in a series Two tanks in a series
One as worker, one as back One as worker, one as back--up up
Audible and visual temperature Audible and visual temperature Audible and visual, temperature Audible and visual, temperature
compensated alarms compensated alarms
O l t t k t l t O l t t k t l t On last tank at least On last tank at least
Designated resins for medical applications Designated resins for medical applications
UF post DI UF post DI
De De--ionization Device ionization Device
Monitoring Monitoring (Operating Parameters) (Operating Parameters)
DI
Monitor: Pressure Monitor: Pressure
before and after each before and after each
Na+
Exchange
Process
Na+
Cl-
Cl-
Na+
Cl-
tank tank
Look For: A change in Look For: A change in
H+
H+
H+ OH-
OH-
Na+
Na+
Na+
Cl-
Cl-
Cl-
H+
OH-
gg
pressure of 10 psi or pressure of 10 psi or
more from baseline more from baseline
H+
H+
H+
H+
OH-
OH-
OH-
OH-
OH-
H+
H+
H+
H+
OH-
OH-
OH-
OH-
Hydrogen Ions
Hydroxyl Ions
Cation Resin Bead Anion Resin Bead
H+ OH-
HH
22
OO
DI Water Quality Monitoring DI Water Quality Monitoring DI Water Quality Monitoring DI Water Quality Monitoring
Monitoring is the same as for Monitoring is the same as for Monitoring is the same as for Monitoring is the same as for
RO except: RO except:
Continuous Monitoring is Continuous Monitoring is gg
done by Resistivity instead of done by Resistivity instead of
Conductivity Conductivity
Resistivity Must Always Be Resistivity Must Always Be
Greater Than 1 MegaOhm Greater Than 1 MegaOhm
Ultraviolet Irradiator Ultraviolet Irradiator Ultraviolet Irradiator Ultraviolet Irradiator
UV is a mercury vapor lamp enclosed in a UV is a mercury vapor lamp enclosed in a y p p y p p
fused quartz sleeve fused quartz sleeve
Endotoxins may be produced as it kills Endotoxins may be produced as it kills
bacteria bacteria bacteria bacteria
Ultrafilter recommended after UV for Ultrafilter recommended after UV for
endotoxin control endotoxin control
UF may be placed at points of use UF may be placed at points of use UF may be placed at points of use UF may be placed at points of use
Check LAL Check LAL
Unit lamp sleeve not routinely cleaned and will Unit lamp sleeve not routinely cleaned and will
ff t ffi i ff t ffi i affect efficiency affect efficiency
Lamp should have a monitor built in to device Lamp should have a monitor built in to device
With or Without monitor, replace lamp once per year With or Without monitor, replace lamp once per year , p p p y , p p p y
Ultra and Submicron Filters Ultra and Submicron Filters
For the removal of bacteria
d d t i and endotoxins
Ultra and Submicron Filters Ultra and Submicron Filters Ultra and Submicron Filters Ultra and Submicron Filters
UF filters rated by pore size UF filters rated by pore size y p y p
generally .01 through 0.1 microns) generally .01 through 0.1 microns)
Sub micron filter Sub micron filter
0.1 through 1.0 microns 0.1 through 1.0 microns
Grow bacteria if not disinfected or replaced Grow bacteria if not disinfected or replaced
routinely routinely routinely routinely
Low flows and high pressure loss through Low flows and high pressure loss through
filters filters filters filters
Record pressure pre and post filter Record pressure pre and post filter
>8 PSI, action taken >8 PSI, action taken
Product Distribution Systems Product Distribution Systems Product Distribution Systems Product Distribution Systems
Pi i l bl f d li i t t ll Pi i l bl f d li i t t ll Piping loop capable of delivering water to all Piping loop capable of delivering water to all
equipment and patient needs equipment and patient needs
Material and construction is very important Material and construction is very important
No branch lines or dead ends No branch lines or dead ends
Loop pressures can be very high when water consumption Loop pressures can be very high when water consumption
is low in piping is low in piping
Velocity greater than 3 feet per second (FPS) at peak Velocity greater than 3 feet per second (FPS) at peak
demand demand
Loop sections repaired or additions with incorrect Loop sections repaired or additions with incorrect
t i l t i l materials materials
Hoses and valves can cause positive bacteria results Hoses and valves can cause positive bacteria results
Microbiological Monitoring Microbiological Monitoring Microbiological Monitoring Microbiological Monitoring
Microbiological Standards for Water Microbiological Standards for Water
Used to Prepare Dialysis Fluid and Used to Prepare Dialysis Fluid and Used to Prepare Dialysis Fluid and Used to Prepare Dialysis Fluid and
Reprocess Hemodialyzers Reprocess Hemodialyzers
Bacteria: Less than 200 CFU/ Bacteria: Less than 200 CFU/mL mL with an with an
action level of 50 CFU/ action level of 50 CFU/mL mL action level of 50 CFU/ action level of 50 CFU/mL mL
Endotoxin: Less than 2 EU/ Endotoxin: Less than 2 EU/mL mL with an with an
action level of 1 EU/ action level of 1 EU/mL mL action level of 1 EU/ action level of 1 EU/mL mL
Sample Collection Sites Sample Collection Sites Sample Collection Sites Sample Collection Sites
Water leaving the RO or DI system Water leaving the RO or DI system Water leaving the RO or DI system Water leaving the RO or DI system
Water leaving a holding tank Water leaving a holding tank
Water returning at the end of the loop Water returning at the end of the loop Water returning at the end of the loop Water returning at the end of the loop
Water entering the reprocessing Water entering the reprocessing
equipment equipment equipment equipment
Water entering any concentrate mixing Water entering any concentrate mixing
equipment equipment equipment equipment
Water entering the dialysis machines Water entering the dialysis machines
Backup Water Plan Backup Water Plan Backup Water Plan Backup Water Plan
If your facility uses a back up water plan If your facility uses a back up water plan If your facility uses a back up water plan If your facility uses a back up water plan
that uses anything other than a that uses anything other than a
replacement RO this water should be replacement RO this water should be replacement RO, this water should be replacement RO, this water should be
monitored for microbiological monitored for microbiological
contamination as well contamination as well contamination as well. contamination as well.
If you perform LAL’s on site, it is If you perform LAL’s on site, it is
recommended that you test the water recommended that you test the water recommended that you test the water recommended that you test the water
before dialysis is initiated in the facility before dialysis is initiated in the facility
Bacteria Testing Methods Bacteria Testing Methods Bacteria Testing Methods Bacteria Testing Methods
Must be assayed within 1 Must be assayed within 1--2 hours of drawing or 2 hours of drawing or
refrigerated at 5 degrees C not longer than 24 hours of refrigerated at 5 degrees C not longer than 24 hours of
collection collection
Use membrane filter technique (including commercial Use membrane filter technique (including commercial
devices) or spread plate method devices) or spread plate method ) p p ) p p
Use pipette for accuracy Use pipette for accuracy
No “calibrated loop” methods No “calibrated loop” methods
Culture media should be trypticase soy agar (TSA) or Culture media should be trypticase soy agar (TSA) or
equivalent equivalent
No blood or chocolate agar No blood or chocolate agar No blood or chocolate agar No blood or chocolate agar
Incubate at 35 Incubate at 35--37 degrees C for 48 hours 37 degrees C for 48 hours
Count viable colonies with a magnifying device Count viable colonies with a magnifying device
Shall not exceed 200 cfu/ml Shall not exceed 200 cfu/ml
If Results Exceed Action Level If Results Exceed Action Level If Results Exceed Action Level If Results Exceed Action Level
Disinfect RO Disinfect RO Disinfect RO Disinfect RO
Reculture Reculture
If still above 50 cfu/ml If still above 50 cfu/ml If still above 50 cfu/ml If still above 50 cfu/ml
Check all previous sample sites Check all previous sample sites
All patient stations All patient stations
Storage tanks Storage tanks
Water to mix dialysate Water to mix dialysate
Final component of water treatment system Final component of water treatment system Final component of water treatment system Final component of water treatment system
All dialysis machines All dialysis machines
Monitoring FlowRates Monitoring FlowRates Monitoring Flow Rates Monitoring Flow Rates
Flow velocity in Flow velocity in yy
distribution loop should distribution loop should
be at least 3 feet per be at least 3 feet per
second second second second
Monitor the flow rate at Monitor the flow rate at
the end of the loop the end of the loop
Calculate the velocity Calculate the velocity
from the flow rate and from the flow rate and
pipe size pipe size pipe size pipe size
V = Q/A V = Q/A
Documentation Documentation Documentation Documentation
“If it isn’t written down, it didn’t happen” “If it isn’t written down, it didn’t happen”
Documentation of technical parameters Documentation of technical parameters
must meet the same stringent standards must meet the same stringent standards
as patient care documentation. After all, as patient care documentation. After all,
IT IS IT IS patient documentation! patient documentation!