CCHT ACE: Water Treatment

*PARTS OF A WATER TREATMENT SYSTEM FROM THE TOP* Trivia: Standard In-Center HD exposes patients to 270-576 liters of water per week! *[SIMPLIFIED VERSION]* *ACID RAIN* |X} *GROUND* |X} *LAKE STREAM* |X} *PUMP STATION* |X} *FEED WATER* |X} *BACKFLOW PREVENTION* |X} *TEMPERATURE BLENDING VALVE* |X} *BOOSTER PUMP* |X} *CHEMICAL INJECTION SYSTEMS* |X} *MULTIMEDIA/SEDIMENT FILTER* |X} *WATER SOFTENER* |X} *BRINE* |X} *CARBON TANKS* |X} *REVERSE OSMOSIS/R.O. SYSTEM* |X} *DEIONIZATION* (Only used in Emergency Back-up for the RO Systems) |X} *ULTRAVIOLET LIGHT (UV)* |X} *DISTRIBUTION SYSTEM* |X} *WATER DISTRIBUTION PIPING SYSTEMS*

*ACID RAIN* (picks up impurities like carbon dioxide and sulfur dioxide gases that makes 'acid rain') |X} *GROUND* (forms calcium carbonate and calcium sulfate when acid rain comes in contact with limestones and other minerals and dissolves them) |X} *LAKE STREAM* (usually picks up microbes and other sediments on the way to the pump station for filtration processes) |X} *PUMP STATION* (Alum is added to clear brown color. Chloride is added to kill bacterias, some cities add fluoride to prevent tooth decay and others change the water pH to reduce levels of metals that might *leach* or dissolve out of pipes into the drinking water) |X} *FEED WATER* (Enters the Dialysis Center water system) |X} *BACKFLOW PREVENTION* (Keeps water from entering the community) |X} *TEMPERATURE BLENDING VALVE* (At a Temperature of 77-82 degrees Fahrenheit or 25-28 degrees Celsius for Reverse Osmosis or RO to work best. Permanent damage to the RO membranes may occur above 95 degrees Fahrenheit or 35 degrees Celsius) |X} *BOOSTER PUMP* (Hydraulic Pressure: 5-8 Gallons. If a pressure is not high enough or consistent enough, booster pump will help) |X} *CHEMICAL INJECTION SYSTEMS* ( Ideal water pH: 5.0-8.5. If pH is above 8.5, carbon filters and RO will not work as well. When this happens, the system will inject a small amount of hydrochloric or sulfuric acid into the feed water to lower the pH) |X} *MULTIMEDIA (A common Sediment Filter)* (Multiple filters of different ratings trap progressively smaller particles such as sediments. Backwashing often occur every night. As the filter clogs, the △P or "delta pressure" reading rises and downstream flow drops. If the pressure exceeds this limit, the filter needs to be backwashed or serviced. Set per clinic's policy) |X} *WATER SOFTENER* [Note: Never let your water softener regenerate during dialysis]. (Water softening takes out Calcium [Ca+] or Magnesium [Mag+]. Water softeners work by ion exchange, whereas ions of calcium and magnesium are removed. These ions are traded for sodium ions, which then form sodium chloride or "salt". Ion exchange takes place in a "bed" of tiny round beads of polystyrene resins. Resin beads are coated with sodium chloride ions that attracts ions of calcium and magnesium and gives up sodium ions of equal charge. When 'exhausted', when the resin has all the calcium and magnesium it can hold, it must be regenerated and saturated again with sodium.) |X} *BRINE* (We generate water softeners by flushing resin bed with water and then with brine, which is a strong salt water. The resin bead exchanges ions, and again coated with sodium ions and the process starts all over again. Unwanted positive ions are the rinsed to the drain) |X} *CARBON TANKS* (A way to remove free chlorine and chloramine. Chlorine levels should be [less than or at] <0.5mg/L. Chloramine levels should be [less than or at] <0.1mg/L. Carbons tanks contains GAC or Granular Activated Charcoal that adsorbs low molecular weight particles from water, like a magnet. The water system must have two carbon tanks; the first tank is called the "worker", and the second tank is the "polisher". Carbon tanks are mainly used to remove: chlorine, chloramines, pesticides, industrial solvents, some trace organics [living or dead substances]. The GAC should have an iodine rating (measure of carbon adsorption) of greater than 900 to remove enough chloramines. Empty Bed Contact Time [EBCT] is the amount of time to generate carbon to adsorb chlorine and chloramines. EBCT is calculated based on the volume of GAC and the maximum water flow rate. CMS requires at least 10 minutes of total EBCT [or 5 minutes per tank] to reduce chlorine or chloramine to level that are safe for dialysis use. *EBCT is calculated using the formula: EBCT = V/Q*) |X} *R.O. SYSTEM* (is way to remove solutes from a solution using a semipermeable membrane and water pressure pump. The most costly and fragile part of the water treatment system. RO uses hydraulic pressure to push water from a solution with high solute levels through a membrane. Salts and other contaminants stay behind. Contaminants and a waste are sent to the drain or back to the feed side of the RO system. The treated water is used for dialysis. The membrane is the key part of the RO system, filters out: metals, salts, chemicals, bacteria, endotoxin, viruses. The most common RO membrane is the Thin Film Composite [TFC] which has a thin, dense membrane over a thick, porous substructure for strength. RO can reject 95-99% of charged ionic particles and nearly 103 to 105 organic and inorganic substances. Parts of the RO system includes: a Cartridge System; is a prefilter placed just before the RO to remove carbon fines [small carbon pieces], resin beads, and other debris. Pressure gauges are placed before and after the prefilter to check for clogging. it is low-cost and protects the expensive RO system filter and it is good practice to change them often. The second part is the RO Pump and Motor Assembly; this is the loudest part of the water system and is used to raise pressure across the RO membrane.) |X} *DEIONIZATION* [Note: Only used in Emergency Back-up for the RO Systems]. (Removes anions [negatively charged ions] and cations [positively charged ions] from water. However, it does not remove microbes because it doesn't have an electric charge. Anions are exchanged for hydroxyl (OH-) ions. Cations are exchanged for hydrogen (H+) ions. OH- and H+ combine to form very pure product water (H2O). Two types of DI systems, includes: Dual bed [keeps anion and cation resin in separate vessels] and Mixed bed [contains cations and anion resin bead; usually make higher quality water than dual bed systems. DI tanks should be large enough to treat more water than you clinic will need to prevent fatality in patients. DI must be monitored by resistivity all the time so the tanks can be exchanged before exhaustion occurs. Portable DI tanks are used in a clinic but regenerated off-site. DI tanks are rarely used [only for Emergency] as the main water treatment. Due to risks, and must use a Resistivity Meter, must have an alarm that can be heard and seen in the patient care room(s). Pure water coming from a fresh DI tank system has a resistivity of 18.3 megohms-cm. When resistivity of the product water drops below 1 megohms-cm; [1] The alarm will sound, [2] The product water is sent to the drain or kept from reaching the point of use) |X} *ULTRAVIOLET LIGHT* (Uses invisible UV radiation to destroy microbes by changing its DNA to they can't multiply or die. It uses a low-pressure mercury vapor lamp housed in a quartz sleeve. Feed water flows over the quartz and is exposed to the UV light. To work, the light must be sized for the highest flow rate your clinic uses. The quartz sleeve must be cleaned so that microbes won't multiply to harmful levels. Lamps must be replaced before it weakens. Older systems, track hours used and change the bulb at set times; light wavelength used must be 254 nanometers and must provide a radiant energy dose of 30 milliwatt-sec/cm2. Newer systems have UV intensity meter to check radiant energy output. If it falls below 16 milliwatt-sec/cm2 [the smallest dose to kill microbes], a visual alarm will go off to tell you that a replacement is needed.) |X} *SUBMICRON AND ULTRAFILTERS* (Membrane filters to reduce microbes in water. Ranges in size from ,05 down to .001 microns. Ultrafilter's are membrane filters that remove bacteria and endotoxin and are most often placed just before the distribution piping. They must be placed downstream from DI tanks, if DI is the last step in water treatment. Clean and disinfect filters: [1] On a set schedule, [2] Or, when a pressure difference between the inlet and the outlet filter gauges exceeds the limit set by your clinic.) |X} *DISTRIBUTION SYSTEM* (Brings water to where it is needed for dialysis. Two types of systems are; [1] Direct feed system, takes RO water right to the product water loop for distribution. Unused product water is sent back to the RO system and/or to the drain. [2] Indirect feed system, takes RO water to a storage tank which then is pumped out through pipes to the points of use. Unused product water is sent to the storage tank by the way of the return loop.) |X} *WATER STORAGE* (This tank should have a tight-fitting lid and be vented by a hydrophobic 0.2 micron air filter, a cone or bowl-shaped bottom that ensures that the tank will empty all the way and be easy to disinfect and rinse. A centrifugal pump made of inert materials is needed to move product water out of the storage tank and through the distribution piping. Chlorine and Chloramines are removed during pretreatment. *This means there is nothing in the product water to prevent the growth of microbes* The tank and pipes are perfect spots for bacteria to grow and form "biofilm", a slime they use to protect themselves. For this reason, we must clean and disinfect the storage tank and distribution piping at least once a month!) |X} *WATER DISTRIBUTION PIPING SYSTEMS* (CMS requires a continuous loop for water distribution piping. Unused product water can go back to a storage tank (or to the RO System, in a direct feed system) to save water. The loop should not have dead ends or multiple branches - these raise the risk of contamination. The most common piping system is Polyvinyl Chloride [PVC]. To reduce the growth of microbes, water flow through distribution system should be: [1] At least 3 feet per second for an indirect feed, [2] 1.5 feet per second for a direct feed system)

*SYMPTOMS POTENTIALLY RELATED TO WATER CONTAMINATION* *Signs/Symptoms* NEUROLOGICAL DETERIORATION

*Possible Water Contaminant-Related Cause* (1) Aluminum

*SYMPTOMS POTENTIALLY RELATED TO WATER CONTAMINATION* *Signs/Symptoms* ANEMIA

*Possible Water Contaminant-Related Cause* (1) Aluminum (2) Chloramines (3) Copper (4) Zinc

*SYMPTOMS POTENTIALLY RELATED TO WATER CONTAMINATION* *Signs/Symptoms* BONE DISEASE

*Possible Water Contaminant-Related Cause* (1) Aluminum (2) Flouride

*SYMPTOMS POTENTIALLY RELATED TO WATER CONTAMINATION* *Signs/Symptoms* NAUSEA and VOMITING

*Possible Water Contaminant-Related Cause* (1) Bacteria (2) Calcium (3) Copper (4) Endotoxin (5) Low pH (6) Magnesium (7) Nitrates (8) Sulfates (9) Zinc

*SYMPTOMS POTENTIALLY RELATED TO WATER CONTAMINATION* *Signs/Symptoms* FEVER and CHILLS

*Possible Water Contaminant-Related Cause* (1) Bacteria (2) Endotoxin (3) Copper (4) Zinc

*SYMPTOMS POTENTIALLY RELATED TO WATER CONTAMINATION* *Signs/Symptoms* HYPOTENSION

*Possible Water Contaminant-Related Cause* (1) Bacteria (2) Endotoxin (3) Nitrates (4) Calcium (5) Calcium (6) Magnesium

*SYMPTOMS POTENTIALLY RELATED TO WATER CONTAMINATION* *Signs/Symptoms* MUSCLE WEAKNESS

*Possible Water Contaminant-Related Cause* (1) Calcium (2) Magnesium

*SYMPTOMS POTENTIALLY RELATED TO WATER CONTAMINATION* *Signs/Symptoms* HYPERTENSION

*Possible Water Contaminant-Related Cause* (1) Calcium (2) Magnesium (3) Copper (4) Sodium

*SYMPTOMS POTENTIALLY RELATED TO WATER CONTAMINATION* *Signs/Symptoms* HEMOLYSIS

*Possible Water Contaminant-Related Cause* (1) Chloramines (2) Copper (3) Zinc

*SYMPTOMS POTENTIALLY RELATED TO WATER CONTAMINATION* *Signs/Symptoms* LIVER DAMAGE

*Possible Water Contaminant-Related Cause* (1) Copper

*SYMPTOMS POTENTIALLY RELATED TO WATER CONTAMINATION* *Signs/Symptoms* SEVERE HEADACHES

*Possible Water Contaminant-Related Cause* (1) Copper

*SYMPTOMS POTENTIALLY RELATED TO WATER CONTAMINATION* *Signs/Symptoms* METABOLIC ACIDOSIS

*Possible Water Contaminant-Related Cause* (1) Low pH (2) Sulfates (3) Copper

*WATER TREATMENT TESTING* (I) *Dialysis Machines Fed By Portable RO Machines*

*Where To Test* - Dialysate sample from dialysate sample port as specified by the machine manufacturer *Which Test(s) and How Often* *MONTHLY* - Colony count and LAL

*WATER TREATMENT TESTING* (F) *Dialysis Machines*

*Where To Test* - Dialysate sample from dialysate sample port as specified by the machine manufacturer *Which Test(s) and How Often* Colony count and LAL on at least 2 machines per month so all machines are tested once per year

*WATER TREATMENT TESTING* (G) *Tap Water*

*Where To Test* - Feed water port located prior to all pretreatment devices *Which Test(s) and How Often* *ANNUALLY* - AAMI chemical analysis

*WATER TREATMENT TESTING* (H) *Portable RO Machines*

*Where To Test* - Product water sample *Which Test(s) and How Often* *MONTHLY* - Colony count and LAL *ANNUALLY* - AAMI chemical analysis at least once a year

*WATER TREATMENT TESTING* (K) *Total Chlorine*

*Where To Test* - Water exiting carbon tank # 1 (before carbon tank # 2) *Which Test(s) and How Often* *Before the first patient shift* and, *Every 4 hours for the rest of the day*

*WATER TREATMENT TESTING* (J) *Total Water Hardness*

*Where To Test* - Water exiting the water softener tank *Which Test(s) and How Often* *END OF EACH TREATMENT DAY*

*WATER TREATMENT TESTING* (B) *RO Loop Pre*

*Where To Test* - Water exiting the water storage tank, before UV or ultrafilters *Which Test(s) and How Often* *MONTHLY* - Colony count and LAL

*WATER TREATMENT TESTING* (E) *Water Feeding The Acid Mixer*

*Where To Test* - Water feeding the acid mixer (water sample - not acid sample) *Which Test(s) and How Often* *MONTHLY* - Colony count and LAL

*WATER TREATMENT TESTING* (D) *Water Feeding The Bicarb Mixer*

*Where To Test* - Water feeding the bicarb mixer (water sample - not bicarb sample) *Which Test(s) and How Often* *MONTHLY* - Colony count and LAL

*WATER TREATMENT TESTING* (C) *RO Loop Return*

*Where To Test* - Water running from the treatment floor, before returning to the water storage tank or RO system *Which Test(s) and How Often* *MONTHLY* - Colony count and LAL *ANNUALLY* - AAMI chemical analysis

*WATER TREATMENT TESTING* (A) *RO Product Water*

*Where To Test* -Water coming out of the RO product port *Which Test(s) and How Often* *MONTHLY* -Colony count and LAL (Limus amoebocyte lysate)

*TRYPTIC SOY AGAR (TSA)*

A medium for growing cultures from water samples

*DEIONIZATION (DI)*

A process to remove ions

*LIMUS AMOEBOCYTE LYSATE (LAL)*

A test for endotoxin

*REVERSE OSMOSIS (RO)*

A water purification system (very expensive filter)

*TRIHALOMETHANES*

Cancer causing substances

*DELTA PRESSURE (△ P)*

Change in pressure level

*THIN FILM COMPOSITE*

Common RO membrane material

*EPA National Primary Drinking Water Standards* Contaminants and Maximum Contaminant Level (mg/L)

Contaminants / Maximum Contaminant Level (mg/L (a) 2, 4-D: 0.07mg/L (b) Antimony: 0.006mg/L (c) Arsenic: 0.010mg/L (d) Atrazine: 0.003mg/L (e) Barium: 2.0mg/L (f) Benzene: 0.005mg/L (g) Beryllium: 0.004mg/L (h) Bromate: 0.01mg/L (i) Cadmium: 0.005mg/L (j) Carbon Tetrachloride: 0.005mg/L (k) Chloramines: MRDL= 4.0mg/L (l) Chlordane: 0.002mg/L (m) Chlorobenzene: 0.10mg/L (n) Chromium: 0.10mg/L (o) Cyanide: 0.20mg/L (p) Dichloromethane: 0.005mg/L (q) Dioxin: 0.00000003mg/L (r) Fluoride: 4.0mg/L (s) Lead: 0.015mg/L (t) Mercury: 0.002mg/L (u) Nitrate (Nitrogen): 10mg/L (v) Nitrite (Nitrogen): 1.0mg/L (w) PCBs: 0.0005mg/L (x) Selenium: 0.05mg/L (y) Thallium: 0.002mg/L (z) Toluene: 1.0mg/L *MRDL* = Maximum Residual Disinfectant LEvel; the highest level of a disinfectant allowed in drinking water.

*CALCULATING EMPTY BED CONTACT TIME [EBCT]*

EBCT is calculated using the formula: *EBCT = V / Q* *V* = the volume of carbon in cubic feet *Q* = the water flow rate in gallons per minute (GPM) To calculate the volume of carbon needed, use the formula: *V = (Q x EBCT) / 7.48* (gallons in one cubic foot of water) Example: You have a flow rate of 10 gpm, and you want an EBCT of 5 minutes. Your calculation would be: *V = (Q x EBCT) / 7.48* *V = (10 x 5) / 7.48 = 6.68* Answer: You need a 6.68 cubic foot carbon tank for each working and polishing tank.

*EMPTY BED CONTACT TIME (EBCT)*

How long feed water must touch GAC (Granular Activated Charcoal/Carbon) in a carbon tank

*COLONY FORMING UNITS (CFU)* [Cfu/mL]

Measure of bacteria in water

*PARTS PER MILLION (PPM)*

Measure of chemical level

*ENDOTOXIN UNIT (EU)*

Measure of endotoxin (a toxic part of the cell walls of some bacteria when they die; pyrogenic reaction occurs to patients) in water

*POUNDS PER SQUARE INCH (PSI)*

Measure of pressure

*GRAINS PER GALLON (GPG)*

Measure of water hardness

*ASSOCIATION FOR THE ADVANCEMENT OF MEDICAL INSTRUMENTATION (AAMI)*

Organization that sets standards for dialysis equipment and water

*GRANULAR ACTIVATED CARBON/CHARCOAL*

Porous carbon that adsorbs chemicals