Water Room

Granuflo

Powdered acid concentrate (or liquid acid concentrate after is has been reconstituted).

Deionization Tank (DI)

A deionizer uses beds of resin beads to remove unwanted ions from the water. The unwanted ions are exchanged for hydrogen and hydroxide ions to form water. * The water used for dialysis will be free from ions that could affect the conductivity of the dialysate. *DI is usually an emergency backup to the RO system and is rarely used as the primary water treatment.

Hydrometer

A device used to measure the specific gravity of acid concentrate after mixing. * The specific gravity must be +/- 2% of the expected range after mixing the acid concentrate.

Phoenix Meter

A device used to verify of each prepared bicarbonate batch. *Used in the clinical are to ensure the final dialysate is properly mixed by measuring pH and conductivity at each patient machine before initiating treatment.

Valve Panel

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

Ion Exchange

A process that occurs inside a Deionizer for water treatment. * Unwanted ions are traded for hydrogen and hydroxyl ions to create pure water.

Hach Pocket Colorimeter

A type of meter used to test for Total Chlorine. It is the primary means of testing Total Chlorine. * This meter is important because it water used in dialysate must be maintained between 0.00ppm-0.09ppm of Total Chlorine.

Action Level

An action level is a level that necessitates taking corrective measures. * The action level for total chlorine is 0.10ppm which requires corrective measures be taken to restore water levels to a safe range for our patients (0.00ppm-0.09ppm).

Total Volume

Defined as the quantity of treated water + the contents of bags or cartons of NutraLyte bicarbonate base powder required to produce bicarbonate base concentrate as stated on the NutraLyte label. * For 4000 series, 1 carton=8L, 1 bag= 96L

Hemodialysis Concentrate Dissolution Unit

Granuflo Mixer

Head Tanks

In gravity feed Solution Delivery Systems (SDS), concentrates (Acid and Bicarb) are pumped into these tanks for delivery to patient stations.

IFU

Indicates "Instructions For Use".

Permanent Labeling

Labeling that is intended to remain on equipment at all times.

Temperature Blending Valve

Mixes hot and cold water to an ideal temperature of 77 F, and should always stay at this level. * A decrease in temp=a decrease in RO membrane efficiency. * A temp gauge/thermometer is placed downstream from the temp blending valve.

Reverse Osmosis (RO)

Reverse osmosis is an important process in the purification of water for hemodialysis because of the large spectrum of solute rejection. * In the RO machine pressure is applied to the incoming water. When the pressure applied to the semi-permeable membrane becomes greater than the osmotic pressure of the solution, the water then travels across the membrane in reverse of the natural occurrence of osmosis. * The RO machine removes: -dissolved inorganic solutes -larger organic solutes with a molecular weight greater than 200 -microbiological contaminants such as endotoxins, viruses and bacteria. -particles from the feed water

Scale

Scale, or Precipitate is solid particles that settle out of a solution and can clog pipes or damage components of a water treatment system. * Hard water contains more minerals and salts and can form scale.

SDS

Solution Delivery System. A device used to mix and/or deliver dialysate concentrate solutions to a single patient station dialysis machine. * The SDS is a gravity- feed or pressurized concentrate delivery system. * The SDS consists of the Bicarb mix tank, bicarb and acid head tank, acid storage tank, and acid and bicarb distribution loops.

Water Storage Tank (Holding Tank)

Tank that holds product water and sends it to the product water loop for use.

Conductivity

The ability of a fluid to transfer an electrical charge. * It is a measure of ions in a solution. * A conductivity meter measures the electrolyte composition of dialysate to be sure it is within safe limits.

Colony-Forming Units (CFU)

The number of CFU in a water or dialysate sample is a measure of the number of living bacteria.

Fill Volume

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

Spec Check Color Standard Kit

The sample cells (vials) in this kit are used to validate the hach colorimeter daily to ensure total chlorine is within safe range of 0.00ppm-0.09ppm.

Empty Bed Contact Time (EBCT)

The time period during which feed water must remain in contact with the charcoal bed in a carbon tank during water treatment. * Feed water must remain in contact with the charcoal long enough to allow adequate removal of chlorine and chloramines. * AAMI standards for carbon tanks = 10 min total EBCT.

TCL-2 (Total Chlorine Log)

This is the log used for BREAKTHROUGH documentation when the total chlorine levels are 0.10ppm or greater after the first carbon tank.

Membrane Filters

Water treatment cartridges containing thin membranes with pores of a specified size, which remove small particles and some solutes.

Carbon Tank

Water treatment devices that contain the granular activated carbon (GAC) that ADSORBS low molecular weight particles from the water. * Carbon tanks are primarily used to remove chlorine, chloramines, pesticides, industrial solvents, and some trace organic substances from the water used in dialysis.

Alternate Water Supply Plan

A plan approved by the Medical Director which provides instructions for the facility should the municipal water supply be interrupted. * This plan ensures the facility can always provide water that meets the AAMI standards for dialysis, even if one or more components of the location's water treatment systems should fail. * This plan should be posted in the water treatment area.

Total Chlorine Testing Algorithm

A tool that can be used by staff to guide them through routine testing and what to do if total chlorine results are at or greater than 0.10ppm.

Depth Filters

A type of sediment filter that may contain one or more layers of fibrous material or mesh. Each layer is finer than the one before to trap smaller and smaller particles. * These filters can remove nearly all floating particles from feed water.

Direct Feed

A water system design in a facility that does NOT have a holding/storage tank. * Ex: Acute dialysis, and home hemodialysis settings.

Indirect Feed

A water system design in the facility that has a holding/storage tank.

AAMI

Association for the Advancement of Medical Instrumentation. * AAMI develops voluntary standards for various aspects of dialysis treatments, including the maximum levels of water contamination.

Bicarbonate

Bicarbonate is a buffer. * In the body it is used to neutralize acids that form when the body breaks down protein and other foods. It is reabsorbed by healthy kidneys. * Dialysis patients often have low levels of bicarb because their kidneys do not reabsorb enough. * Bicarb is used in dialysis to restore levels of bicarb in the patient's body.

Chlorine and Chloramines

Both are harmful to our patients and must be removed from the water used to prepare the dialysate solution. * C & C can cause hemolysis of the red blood cells. * Together chlorine and chloramines form Total Chlorine.

Brine Tank

Brine is concentrated saline solution. * Water softeners require brine tanks which hold salt pellets and water. * The salt and water create a solution to regenerate the softener (Exchange of magnesium and calcium ions for sodium ions)

Chemical Feed System

Chemical injection systems are used to lower feed water pH within reverse osmosis (RO) water purification systems. * Acid injection system is used to correct feed water alkalinity or pH greater than 8.0. * Higher pH or alkaline water is responsible for less adsorptive capacity of the GAC.

Sediment Filters

Components of the dialysis water treatment system that trap undissolved particles such as sand and mud before they can reach the RO membrane and damage it.

Sediment Filter-Cartridge Type

Consists of a cylindrical cartridge of filter media with a central drainage core. Filters out particles from feed water, carbon fines, and water softener resin.

Filters

Devices that remove particles, solutes, and other substances by passing them through holes of various sizes.

Feed Water

Feed water is tap water before it passes through a water treatment system, and must pass through all various components of the system before use in dialysis.

Backwashing

Forcing water backwards through a filter. * This technique can be used to remove accumulated particles from clogged sediment filters in a water treatment system.

GAC

Granulated Activated Carbon Filters- The primary method used in hemodialysis water purification systems to remove Total Chlorine. * GAC removes total chlorine through adsorption. * These filters must be maintained and monitored.

Breakthrough

Has occurred when the test results after the first carbon filter indicate a level at or above the action level of 0.10ppm. * These results are documented in TCL-1 log only ONCE. * A line is placed through all unused documentation sites on the TCL-1 log and TCL-2 log is then started.

HMIS

Hazard Materials Identification System. A permanent labeling required on SDS equipment which uses colored bars, numbers, and symbols to alert staff of hazards of chemicals.

Temporary Labeling

Labeling to mix tanks that will need to be changed as the contents of the mix tanks change. * Unattended mix tanks containing a solution must have a sing displayed that identifies the solution in the tank, this label MUST be in a conspicuous place.

Percent Rejection

Percentage that provides and indication of how effective the RO membrane is at removing contaminants from the incoming water. * Percent rejection must be 95% at the time of installation and whenever membranes are replaced. * Action must occur: -If there is a radical change in the RO percent rejection -Unscheduled AAMI chemical analysis taken when the RO percent rejection reaches 95%, 90%, 85%, and 80%

Delta Pressure

Pressure gauges on different pieces of water treatment equipment must be monitored by measuring the delta pressure. * The standard Delta Pressure is established by taking the pre-filter pressure of a new filter and subtracting the post filter pressure. * The allowable limit will be the filters standard delta pressure +10psi, OR plus manufacturer limit (whichever is less) * Action should be taken on any pressure that is exceeding, according the manufacturers guidelines and FMC guidelines to ensure the water system provides quality water for patients at all times.

Sediment Filter-Multimedia

Sediment filters are used in the pre-treatment portion of an RO system, located prior to the carbon filters, and are one of the most common means of removing particles. * Remove large particulate matter from incoming water. * The filter bed contains multiple layers retaining progressively smaller and smaller particles. * Particles as small as 10 microns can be removed. * They may also be called sand, depth, or bed filters, and are not required at all facilitates.

RPC Ultralow Total Chlorine Strips

Test strips used as a backup if the Hach Colorimeter is out of service as another method of testing for total chlorine in the water. It may also be used in some facilities as the primary method of testing.

Microbiological Testing

Testing used to determine if microorganisms are present at a specific site. * Used as a means to monitor compliance with company and AAMI standards. * Helps ensure patient safety, and AAMI quality water/dialysate in regard to endotoxins and bacteria.

Booster Pump

The device used to increase a center's water flow and pressure if there is a drop. * The water treatment system needs to maintain constant water flow and pressure.

Bicarbonate Mixer

The device used to mix the Bicarbonate concentrate solutions. * Bicarb mixers are used in facilities that use jugs and do NOT have an SDS system.

Frequency of ROUTINE Total Chlorine Testing

The frequency of total chlorine testing for routine documentation is prior to the beginning of the first patient treatment, and not to exceed every 4 hours thereafter.

Low Range (LR)

The hach colorimeter should always be set in the low range (LR) setting. Always verify the LR setting before using the hach colorimeter to check Total Chlorine levels.

15 Minutes

The length of time the Reverse Osmosis (RO) must be running before water samples may be obtained for RO water sample, and Total Chlorine testing.

Initial Volume

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

0.00ppm-0.09ppm

The total chlorine levels that are within a safe range for dialysis patients.

Microns

The unit of measurement for filter pores. * Filters with high micron sizes trap large particles, but allow smaller ones to flow through. * A submicron filter may be required to capture very small particles.

Reject Water (Concentrate)

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

TCL-1 (Total Chlorine Log)

This log is used for ROUTINE daily total chlorine testing documentation of safe ranges between 0.00ppm-0.09ppm

"High Chlorination of the Water Supply" Testing

This testing is performed when the city water department adds extra chlorine to the water supply, usually due to a break in the water main, flooding, or bacterial contamination. * The GAC testing will increase to every hour until the period of increased chlorination has passed.

Adsorption

To adsorb means to attract and hold on to a surface. Adsorption is the binding of chlorine and chloramine molecules to the Granulated Activated Carbon (GAC)surface. * The GAC attracts chlorine and chloramines to the surface of the carbon like a magnet.

Total Chlorine

Total Chlorine = Free Chlorine + Combined Chlorine *Example: Total Chlorine = hypochlorite, aka bleach (free chlorine) + chloramines (combined chlorine) * Free chlorine is unbound and Combined chorine is bound.

Ultraviolet (UV) Light

UV light delivers a lethal dose of radiation to eradicate bacteria as a method of controlling bacterial proliferation in processed water. Located on the SDS, generally followed by an ultrafilter to catch killed bacteria.

Water Softener

Used in water treatment to reduce the concentration of calcium and magnesium that can form scale. * Water softeners work by a process called ion exchange- ions of calcium and magnesium are removed from the water by a bed of electrically charged resin beads and then traded for sodium ions, which form sodium chloride.

Ultrafilter

Used to control and remove particulates, bacteria, and endotoxins (pyrogens) and other microorganisms. It controls and removes any particulates or microorganisms that may be present in the water system and harmful to our patients.

Backflow Prevention Device

Used to keep water from flowing backward into the incoming water supply, keeping any contaminants removed by the water treatment system from getting into the water feed. * Most cities require the backflow prevention device be installed at the start of the water treatment system.

Product Water

Water that has been forced through a reverse osmosis membrane.