Water system Study guide

Chlorine breakthrough procedure

1.If this occurs post carbon tank 1 (worker) immediate action is to put all machines in bypass and implement action plan. Additional testing should take place after carbon tank 2 (polisher). 2. If test shows results above limit after carbon tank 2 immediately stop all treatments. 3. If test shows results below limit after carbon tank 2 then treatments may be resumed per Medical Director approval. (Must be checked every 2 hours and doc in TMS). This requires notification of medical director, clinical manager, director of operations, and Regional technical operations manager

Hydrometer

A device used to measure specific gravity of acid concentrate after mixing.

Valve Panel

A panel or wall box where bicarb concentrate, acid concentrate and RO water are centrally delivered for use by hemodialysis machines.

Direct feed

A water system design in a facility that does NOT have a holding tank. Ex: acute and home HD.

Indirect feed

A water system design in a facility that has a holding tank

Chemical Feed pumps

Adjusts the pH level of the water

Air (expansion/bladder) tank

Assists in maintaining minimum water pressure

AAMI

Association for the Advancement of Medical Instrumentation. Their purpose is the development, management, and use of safe and effective health technology.

Grows rapidly and may produce endotoxins or biofilm

Characteristics of bacteria and/or viruses:

chlorine and ammonia

Chloramines are combination of what two chemicals?

Bacteria and endotoxin testing

Completed every month, fkc action level for bacteria is 20 cfu/ml, action level for endotoxins is 0.125 EU/ml in RO, action level for endotoxins in tank water, piping and distribution loop is 0.25 EU/ml. Must implement action plan involving testing higher than allowed limits.

Bicarb jugs

Disinfect with 1:100 bleach water and then rinse with RO water until negative for bleach, disinfect weekly

DADU

Dry Acid Dissolution Unit

Backflow Preventer

First piece of equipment that the water goes through in the dialysis facility. Prevents water from flowing back into city water supply and contaminating the city water supply. Not required by AAMI or CMS.

Backwashing

Forcing water backwards through a filter. It can be used to remove particles from clogged sediment filters in a water tx system. Rinses debris down the drain, reduces bacteria growth, and helps spread media evenly through the tank. Happens on a regular schedule after hours. Time clocks must be checked daily.

UV Light

Form of invisible radiation that kills bacteria through sterilization (unable to reproduce)

Total chlorine

Free Chlorine + Combined Chlorine

GAC

Granulated Activated Carbon

HMIS

Hazardous Material Identification System

Water Storage Tank (holding tank)

Holds product water and sends it to the product water loop for use.

Brine tank

Holds salt pellets mixed with water for the softener

77 degrees

Ideal water temp for RO operation (range is between 60-85 in F). Water that is too cold or too hot will result in changes to the membrane.

Head Tanks

In gravity feed solution delivery systems (SDS), concentrates (acid and bicarb) are pumped into this equipment for delivery to patient stations.

Water booster pump

Increases incoming city water pressure to make sure that the water makes it through all components of the water treatment system. Not required by AAMI or CMS.

IFU

Instructions for use

Aluminum, chloramines/chlorine, copper, zinc

List the different kind of contaminants found in tap water:

TCL-2

Log used for breakthrough documentation when total chlorine levels are 0.10 ppm or greater after the first carbon tank

TCL-1

Log used for routine daily total chlorine documentation of safe ranges between 0.00 and 0.09 ppm

Deionization Tanks

Method of water treatment used during RO failure and are part of the "alternate water supply plan"

Mixing bicarb

Mixed per policy and procedure, mixing not to exceed 10 minutes, must be used same day

Temperature blending valve

Mixes hot and cold water to ideal temp of 77 deg F.

Over Temperature alarm

Monitors temp of feed water and sounds when becomes too warm (90 deg F). Not required by AAMI or CMS.

pH and conductivity

Must be tested using dialysate before patient treatment. Must be tested using calibrated Myron or Phoenix meter.

Residual Bleach Test

Must be used after bleach disinfection

Delta pressure

Pressure difference pre and post filter, limit 10psi

Leak detector

Prevent water damage from leaks or broken pipes. Sensor placed on the floor and box placed on the wall.

RO (Reverse Osmosis)

Product water exits this component and meets the AAMI standards for water used for dialysis, Performance is measured by percent rejection, Membranes must be replaced at 80% rejection, TDS is measured and document daily, Water exceeding TDS alarm will be diverted to drain

Percent rejection

Provides an indication of how effective an RO machine is at removing contaminants from incoming water, must be 95% when installed and when membranes are changed, action must be taken when there is a radical change in rate.

low level alarm

RO holding tank ___ _____ _____ must be on AT ALL TIMES

Bacteria can cause sepsis, bacteria and viruses can cross a dialyzer membrane, endotoxin is released from the cell wall of dead bacteria

Reasons why bacteria and endotoxins are removed:

Ultrafilters

Remove bacteria and endotoxin and are located after the RO machine

Water Softener

Removes calcium and magnesium through the process of ion exchange

Carbon Tank

Removes chlorine, chloramines and other organic material through the process of adsorption, AAMI requires a minimum of 10 minutes EBCT, FKC requires a minimum of 12 minutes EBCT

Sediment filter

Removes larger particles from the incoming water (10 microns or larger)

Hurricane filter

Removes sediment using 1 large rounded filter.

Cartridge filter

Removes sediment using 4 small rounded filters. Used to protect equipment. Removes various size particles depending on the filter used. Requires routine replacement.

Multimedia filter

Removes sediment using different layers of filters typically includes sand, garnett, anthracite. It works to protect equipment. Not required in all clinics.

Total Chlorine Testing

Ro machine runs for 15 miutes before any checks, must be documented by 2 qualified staff members, 100 ml of water to test(cup must be rinsed 3 times prior to final collection), test strips are immersed in the water for 60 seconds, must be tested prior to dialyzing patients in the morning and at least every 4 hours during treatments, checked after worker carbon tank and post RO, must be less than 0.1ppm (0.00-0.09 ppm), must be documented in TMS

Product Water Divert Valve

Sends water to the drain when it exceeds the TDS alarm limits.

Water Hardness

Tested post water softener, Measured in ppm, must be under 20 ppm, must be checked twice daily, tests for calcium and magnesium, cup must be rinsed 3 times before final test sample is collected, doc per clinic

high chlorination of the water supply testing

Testing is performed when the city adds extra chlorine in the water supply, due to break in main, flooding or bacterial contamination. GAC testing increased to hourly.

Water pathway

The _____ _______ in the dialysis facility begins where the city water enters the facility.

Empty bed contact time (EBCT)

The length of time that water is exposed to carbon

1.5ft for direct, 3ft for indirect

The optimal flow rate for water through the water TX system is?

Initial volume

The quantity of treated water in the mix tank prior to adding bicarbonate concentrate powder

Total volume

The quantity of treated water plus the NaturaLyte bicarbonate base powder required to produce bicarbonate base concentrate as stated on the label

Fill volume

The quantity of treated water plus the number of bags of acid base powder required to produce the total volume of acid base concentrate as stated by the manufacturer.

Reject water

The waste or reject stream that is sent to the drain, along with any solutes removed by reverse osmosis.

Adsorption

To attract and bind to a surface. The binding of chlorine and chloramine to the GAC. The GAC attracts chlorine to the surface like a magnet.

TDS

Total Disolved Solids

Feed water

Untreated tap water before it passes through a water treatment system.

Product water

Water that has been forced through a reverse osmosis membrane

Exposure to chlorine and chloramines (total chlorine can easily cross the dialyzer membrane causing hemolysis), high temperatures, kinks in bloodlines, and hypotonic solutions.

What are the causes of hemolysis?

Bicarb will not mix properly, reduced flow through membranes, carbon tanks will not remove chlorine was well

What can happen if the water is too cold through the water system?

Increased flow through the membranes, damage to the membranes, pre treatment equipment could be damaged

What can happen if the water is too hot through the water system?

Exposure to bacteria and endotoxins

What causes a pyrogenic reaction?

Fever and chills, nausea, vomiting, low BP

What patient symptoms indicate a pyrogenic reaction?

Low BP, Chest pain, SOB, Cherry soda colored blood

What patient symptoms indictate hemolysis?

Water emergency

When multiple patients are experiencing symptoms of a pyrogenic reaction, what should you suspect is the issue?

Power failure can cause equipment not to backwash, Time changes can put the backwash on a different time schedule (daylight savings time). In either instance, if the backwash happens while patients are dialyzing it come result in patient injury.

Why is it important to check timers in the water room?

Patients are exposed to large amounts of water during dialysis, therefore, the water must be treated to ensure it is free from harmful contaminates. Chlorine and chloramines are added to city water to reduce or eliminate bacteria.

Why is water treated for dialysis?

Piping

______ of the distribution loop can be made of PVC, stainless steel, PEX, or Teflon

CFU

colony forming unit