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Acknowledgement
1.0 Introduction 3
8.0 References ..
Building Services I [BLD 60403] Water Treatment for Domestic Water Supplies 2
ACKNOWLEDGEMENT
We are thankful to our lecturer, Mr. Leong Boon Tik for his valuable guidance,
inspiration and co-operation during the course of this module and this report.
We are also grateful to receive help from Madam Parameswary and Mr. Tee Khay
Sing from St. John Ambulance Malaysia that had went out of their way to explain as well as
to introduce us to their system. It was their helpful support and effort which resulted in this
successful report. We would also like to extend our appreciation to their kindness of granting
us the permission to visit their operating centre amidst their busy schedule.
Finally, we avail this opportunity to convey our most sincere thanks and appreciation
to all individuals who have assisted us directly and indirectly for the accomplishment of this
report.
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1.0 INTRODUCTION
Water is the universal solvent. It dissolves anything that it comes in contact with.
Pure water comes from the water droplets formed in clouds and falls as rain. However, as it
falls, it picks up particles and gases mixed in the surrounding air and even more contaminant
before it reached the ground. Hence, water treatment is crucially vital for the consumption
and for any relevant usage as such contaminants are bad for our body.
Water treatment can be said as any process that makes water more acceptable for a
specific end-use. The end use may be drinking, industrial, medical applications or many
other uses, including being safely returned to the environment. The aims of the water
treatment are to remove unwanted contaminants and undesirable components such as
remove sediment, bacteria, and other impurities from raw water.
Taking a look at the healthcare industry, let it be hospitals or any related healthcare
facilities, water is highly relied on for various purposes. From operational use to disinfection
of used equipment and consumption for patients, treated water has to meet its required
standards and specifications before and after being widely used by many.
Water treatment plays a vital role in the delivery of safe and effective haemodialysis
(HD). Ensuring that water quality meets the American Association for the Advancement of
Medical Instrumentation (AAMI) standards and recommendations is necessary to reduce the
incidence of chemical hazards associated with the use of water for HD. A water treatment
system for renal dialysis consist of three basic sections: a pre-treatment, RO system and a
post-treatment section.
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2.0 WATER TREATMENT PROCESS
Clean, safe water is vital for everyday life. Water is essential for health, hygiene and
the productivity of our community. The choice of method will depend on the quality of the
water being treated, the cost of the treatment process and the quality standards expected of
the processed water, but the basic principles are largely the same.
Sedimentation: Over time, the now-larger particles (flocs) become heavy enough to settle to
the bottom of a basin from which sediment is removed.
Filtration: Then the water travels through large filters made of sand, gravel, and anthracite.
Filtration removes any remaining microscopic particles and microorganisms.
Disinfection: To protect against any bacteria, viruses and other microbes that might remain,
disinfectant is added before the water flows into underground reservoirs throughout the
distribution system and into your home or business. Chlorine is a very effective disinfectant.
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3.0 IMPORTANCE OF WATER TREATMENT
Water is necessary for human health and well-being as we can practically say that
there can be no life on Earth without water. As a matter of fact, the human body is composed
of 70% water. Natural water resources like rivers, lakes, which provide water contain a lot of
pollution, garbage unfit for consumption. Unfiltered water contains chlorine, fluoride, dioxins,
parasites, etc. those could be hazardous to ones health.
Naturally found water may not be as pure as one might think as it contains many
dissolved as well as suspended impurities in them. Due to rapid urbanization and
industrialization, water pollution is becoming more frequent and if these hazardous water
reaches the wide population use before proper treatment, serious health complications or
death might occur.
Water contaminants can come in various forms like biological or chemical state.
Biologically, microorganisms present in drinking water could carry water borne diseases like
cholera, typhoid, round worm infestation and gastric problem. Chemically, on the other hand,
could bring other complications like skin infection, organ disorders and damage to human
nervous system. As mentioned earlier that industrialization is becoming more rapid, these
chemical hazards could greatly affect the health of people.
Water can do harm to humans body if not purified properly. Water treatment is
therefore designed to eliminate or reduce certain pollutants. From boiling to filtering and
even chemical disinfection, various water treatment system methods are found to treat water
in various settings. As all living things on Earth basically depends on water to stay alive, it
can be said that water treatment should now be a basic to ensure a healthy and safe
upbringing of life.
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4.0 TYPES OF WATER TREATMENT IN DOMESTIC
Many individual water supply sources in the Appalachian region are of a quality that
they require some level of treatment to make it acceptable. The type of treatment system
required is centred on the type and concentration of contaminants and to some degree the
level of water consumption. Water supplied to domestic properties may be further treated
before use, often using an in-line treatment process. Many propriety systems also claim to
remove residual disinfectants and heavy metal ions. A good water treatment is very important
to domestics such as water filter. A water filter provide better tasting and better smelling
drinking water by removing chlorine and bacterial contaminants.
1. Softened Water
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2. Activated Carbon Filters
Activated carbon filters used for home water treatment typically contain either
granular activated carbon (GAC) or powdered block carbon. Although both are effective,
carbon block filters generally have a higher ratio of contaminant removal. The two most
important factors affecting the efficiency of activated carbon filtration are the amount of
carbon in the unit and the amount of time the contaminant spends in contact with it.
Therefore, the more carbon you have, the better.
Activated carbon is carbon which has a slight electro-positive charge added to it,
making it even more attractive to chemicals and impurities. As the water passes over the
positively charged carbon surface, the negative ions of the contaminants are drawn to
surface of the carbon granules, acting like a magnet.
Activated charcoal is carbon that has been treated with oxygen. The treatment
results in a very porous charcoal. These tiny holes allow liquids or gases to pass through the
charcoal and interact with the exposed carbon. The carbon adsorbs a wide range of
impurities and contaminants, including chlorine, odours, and pigments. Other substances,
like sodium, fluoride, and nitrates, are not as attracted to the carbon and cannot be filtered
out because adsorption works by chemically binding the impurities to the carbon. The active
sites in the charcoal eventually become filled, leaving you with having to replace your filter.
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3. Sediment Filters
4. Ultraviolet Disinfection
Use of ultraviolet (UV) radiation to kill various organisms is commonly employed for
both domestic and municipal water supplies. Specially-made low-pressure mercury lamps
create fairly strong UV radiation which is effective in disinfecting relatively clear water from
bacteria and viruses. Protozoans that are common to surface water sources are unaffected
by UV treatment. If the water is turbid, the effectiveness of the UV lamps is diminished. It is
common practice to install a filter prior to the UV treatment system. These filters will
eliminate some of the protozoans that are unaffected by the UV and will reduce any turbidity.
One downside to using UV radiation to disinfect water is that there is no continuing or
residual effect as there is with chlorine introduction. So, any bacteria introduced after the
water passed under the light are not killed. Additionally, there needs to be a fairly consistent
source of electricity or water will pass through the system untreated.
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5. Reverse Osmosis Water Filter System
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5.0 INSTALLATION PROCESS
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Figure 7: Drain Clamp Assembly
At a point approximately six (6) inches above the trap, drill a 5/16 diameter bole
through one wall of the pipe. Attach the drain clamp; making sure that the hole in the
clamp is aligned with the hole in the pipe. Use a punch or drill bit to align the holes
while tightening the clamp. Be careful not to over tighten the clamp.
Procedures:
Mark the center with center punch for the 1/4" pilot hole.
Carefully drill pilot hole with masonry pit through porcelain and stop when
metal shows. (Use light pressure and slow speed)
Switch the bit to a standard metal cutting bit to continue to cut through the
metal below the porcelain surface.
Continue to enlarge the pilot hole with larger masonry & metal cutting bits
until the hole is 1/2".
Procedures:
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Mark the center with center punch for the 1/4" pilot hole.
Continue to enlarge hole with larger size drill bit until it is 1/2".
Disassemble hardware from the treaded shank. Chrome base plates and
rubber washers slide up the shank to the faucet body.Feed threaded shank
through the sink hole and orient the faucet. From below sink, slide lock
washer and hex nut over threaded shank and tighten with a wrench.
Note: It is best to have someone hold the faucet from above the sink to keep it from
moving out of place. If this is not possible then tighten the hex nut until it is just
slightly less than completely tight. Then turn the faucet base from above the sink,
tightening it while orienting the faucet in the desired location.
The John Guest Angle Stop Valve provides a simple, easy connection between
the angle stop and the bottom of the riser tube. It has built-in shut-off and
provides the feed supply connection.
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Drain Saddle Valve Installation
A Drain Saddle is used to make a wastewater connection with the drain under
the sink, which is designed to fit around a standard 1-1/2" OD drainpipe. The
drain saddle valve should always be installed before (above) the p-trap and
on a vertical or horizontal drain. Do not install the drain saddle near a garbage
disposal to avoid clogging the drain line with debris.
RO Component Installation
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Step 6.RO Unit Location
The RO unit is normally mounted to the right or left sink cabinet sidewall, depending on
where supply tank is to be located. Generally the unit is installed at the front of the
cabinet and the tank at the rear.
To mount the unit, elevate it at least 2" off the floor, level it and mark the location of
mounting holes needed. Drill hole for mounting screws and install screws allowing the
mounting bracket slots to slip over them.
Note: Make sure all inserts, sleeves and ferrules provided in the installation kit
are used.
Building Services I [BLD 60403] Water Treatment for Domestic Water Supplies 15
so, open the valve of the cold-water self-piercing valve (turn counter clockwise to
open). Check for any leaks around the valve. If any leaks are detected turn off cold
water supply valve and make necessary repairs.
Open the reverse osmosis faucet on the sink. You will hear a gurgling noise. This is
normal air being cleared from the system. It will take approximately 10-15 minutes
before you actually see water dripping from the reverse osmosis faucet. (Flip the
faucet handle up to keep the faucet open during this time.) The initial water dripping
from the faucet may be black in color; this is the water flushing carbon fines from the
carbon post filters. Allow the water to drip from the faucet for 10-15 minutes then
close the faucet
Now open the ball valve on the reverse osmosis storage tank, which will allow the
tank to fill. This will take approximately 4-10 hours. During this period of time check
all fittings for any leaks. If any leaks are found turn off cold-water line and make the
necessary correction. Once the tank is full open the faucet and drain the system
completely (until you are getting only a drip from the faucet). Shut the reverse
osmosis faucet off and allow the system to re-fill.
It is recommended on new installations that you drain the system 3 times prior to
use.
Make a daily check for any leaks during the first week after installation and check for
leaks occasionally thereafter.
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6.0 CASE STUDY
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In 2002, SJAM achieved the recognition of the ISO 9001:2000, a quality
management system standard designed to help organizations ensure that they meet the
customers and other stakeholders needs and at the same time meeting the statutory and
regulatory requirements of related programmes. SJAM also entered into the Malaysia Book
of Records with two records namely the first NGO and the first NGO Haemodialysis Service
to receive ISO 9001:2000, which is upgraded to 9001:2008 in 2010.
Haemodialysis Centre (Station 2)
Apart from ambulance service and first aid services, SJAM also contributes to
the development of haemodialysis services. SJAM Selangor Coastal Area (SJAM -
KPS) started their first Haemodialysis Centre in Klang with only two dialysis machine,
which was both donated to them.
6.2.1.1 IMPORTANCE
Suitable water quality is one of the utmost vital components in ensuring a safe and effective
manner of water delivery to haemodialysis patients. According to The Agency for Clinical
Innovation (ACI), a leading agency for promoting innovation and designing new models of
healthcare facilities in Australia, haemodialysis patients are exposed to approximately 300
litres or more of water per week during dialysis treatment while a healthy adult would
consume about 10-14 litres of water per week. This near 30 times increase in water
exposure to dialysis patient comparing to the average population requires a tight control as
well as monitoring of water quality. Exposing dialysis patients to untreated water may cause
severe effects as these contaminants are now directly exposed to the patients blood via
dialyzer membrane. Unlike a healthy adult with healthy kidneys, dialysis patients do not have
such healthy organs to maintain the normal balance of chemicals within their body.
The water used originates as drinking water but undergoes additional treatment. This
meant that complications related to chemical contamination, such as the hard water
syndrome, were not unusual. It is now well known that many of the chemical substances in
municipal water are potentially dangerous for dialysis patients, some of which (calcium,
sodium, aluminium, chloramines, fluoride, copper, zinc, sulphates, nitrates) are able to lead
to well-defined acute or chronic poisoning syndromes.
Chemical contaminants may give rise to haemolysis and encephalopathy whereas, bacterial
contamination may give rise to acute pyrogenic reaction and production of pro-inflammatory
cytokines, which can eventually lead to amyloidosis, suboptimal response to Erythropoiesis
Stimulating Agents (ESA), malnutrition and accelerated atherosclerosis.
Hence, if anything less than ultra-pure water is used during the dialysis treatment, a
variety of problems could happen. The composition of the dialysis fluid plays an important
role in the modulation of complications associated with end-stage renal disease, as well as
those associated with the treatment itself. The avoidance of complications arising from water
contaminants requires a constant and vigorous attention to water quality to ensure that such
impurities would not cause serious harm to the patients.
Building Services I [BLD 60403] Water Treatment for Domestic Water Supplies 21
6.2.1.2 STANDARD/ GUIDELINE
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6.2.2 REVERSE OSMOSIS IN HAEMODIALYSIS
The reverse osmosis (RO) system uses a pump to push water through a
semipermeable membrane or filter which removes almost all of the contaminants including
bacteria and viruses. Other parts of a RO systems include a carbon filter which absorbs the
chemicals added by the water department and a sediment filter which traps large pieces of
debris. If the water is very hard, a softener will be installed which removes calcium and
magnesium because these substances could damage the RO system.
RO is a technology that is found anywhere pure water is needed. Some common uses
include: drinking water, laboratory applications, water used in chemical processes,
houseplants, greenhouses, and haemodialysis. The RO machine produces two types of
water: product water and reject water.
All dialysis centres use water purification equipment to purify water for dialysis. RO is the
most trusted water purification technology used in purifying water for haemodialysis process
because these devices remove dissolved inorganic solutes as well as bacteria and
endotoxins. RO has proven itself to be the safest, most economical method of purifying
water for dialysis and most reliable water purifier system that is designed to produce water to
ensure safe, high quality care for haemodialysis patients.
Water plays an important, life-sustaining role for dialysis patients. As we know, certain
contaminants in water supplies can cause severe complication especially to dialysis patients.
Hence, trustable water treatment systems are greatly dependant for dialysis patients and RO
is the system practised by SJAM widely in their haemodialysis service.
Building Services I [BLD 60403] Water Treatment for Domestic Water Supplies 23
6.2.3 DESIGN CONSIDERATION
Referring to the ACI guide for in-centre dialysis water and the Ministry of Health Malaysia,
the planning consideration for the design and installation of water treatment system in
dialysis centre should follow but not limited to the following:
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6.2.4 COMPONENTS & PROCESS
WATER SUPPLY
From the municipal water supply, water enters and is store in this pre-filer raw water tank. It
can take up to 450 gallons of water. In this tank, water is considered not clean enough to be
used as it still contains sediment and other contaminants.
Backflow preventer
A backflow prevention device is used on water pre-treatment pathways to stop the water in
the water pre-treatment system from flowing back into the source water supply system. This
protects drinking water from contamination with disinfectants and cleaners that are used in
dialysis water treatment systems
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WATER TREATMENT SYSTEM PROCESS FOR HAEMODIALYSIS
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Raw Water Tank Pre-Filter
Rocket Filter
Figure 19
Figure 20
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Auto Sand Filter
Brine Tank
Softener needs regenerating with concentrated
sodium chloride solution (brine) before exhausting
Figure 22 & 23:
Blue brine tank its resin capacity
connecting to softener Salt is added weekly and stir continuously until it
becomes concentrated solution
Building Services I [BLD 60403] Water Treatment for Domestic Water Supplies 28
R.O Plant/ Module
Most critical part of water treatment system where
purified water is produced through reverse osmosis
Feed water is forced to flow in opposite direction across
a semi-permeable membrane to the compartment with
less concentration of solutes
Semi-permeable membrane size is 0.5 1 microngram
Incoming water split into 2 streams where purified water
that crosses the membrane is directed to storage tank
R.O Systems
Figure 25
Figure 26
UV Sterilizer
Figure 27
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R.O Water Pump #1 #2
Reprocessor
Pressure gauges
Figure 30
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DISTRIBUTION SYSTEM
Also referred to as the RO water loop, RO distribution systems can be grouped into two
categories:
Building Services I [BLD 60403] Water Treatment for Domestic Water Supplies 31
In this centre, storage tank are no longer used to store product water as it is not
directly pumped to dialysis machines. They started adopting the direct systems due to:
Dialysis water is constantly monitored & Poor tank design may lead to stagnation
sent to drain if unclean enough and contamination if inadequate air filter
This direct system is also equipped with UV sterilizer hence it gives an additional protection
against bacterial contamination but another issue that might arise from this is that it requires
higher water consumption due to continue reject water to drain.
Building Services I [BLD 60403] Water Treatment for Domestic Water Supplies 32
PRODUCT WATER
Product water is then directed to either reprocessor or dialysis machine for their
respective usage.
Dialysis machine A machine used in dialysis that filters a patient's blood to remove
excess water and waste products when the kidneys are
damaged, dysfunctional, or missing. The dialysis machine mixes
and monitors the dialysate. Dialysate is the fluid, combining
product water and other solutes that helps remove the unwanted
waste products from your blood. It also helps get your
electrolytes and minerals to their proper levels in your body. The
machine also monitors the flow of your blood while it is outside of
your body. You may hear an alarm go off from time to time. This
is how the machine lets us know that something needs to be
Figure 40
checked.
Figure 41
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DISINFECTION
Disinfection of the distribution piping system shall happen on a regular basis. The type of
distribution piping system and the disinfection method to be used will influence how often
disinfection is carried out. There are two types of disinfection methods.
1. Chemical disinfection: When the manufacturer recommends chemical disinfectants,
means shall be provided to restore the equipment and the system in which it is installed
to a safe condition relative to residual disinfectant prior to the product water being used
for dialysis applications. Test for residual levels of the disinfectants should also be
carried out regularly.
2. Hot water disinfection: When used to control bacterial proliferation in water treatment,
storage, and distribution systems, the water heater of a hot water disinfection system
shall be capable of delivering hot water at the temperature and for the exposure time
specified by the manufacturer (minimum distribution loop temp 60 C). Heat disinfection
will not remove established biofilms, but is convenient, requires little rinse time and can
thus be used more often to prevent biofilm formation. An occasional chemical
disinfection might still be necessary. Note: PVC piping shall not be used with heat
disinfection.
Building Services I [BLD 60403] Water Treatment for Domestic Water Supplies 34
REPROCESSOR
Process:
Used dialyzer is plugged into the reprocessing station which takes roughly about 10
minutes to be completely disinfected and ready for the next use
Maintenance:
Technicians inspects the reprocessing machines every 6 months once, including the
exterior inspection for any defects such as bent or broken switches, cracks in cover,
corroded metal parts, loose or missing hardware as well as excessive protein
deposits in the tubing
Backup (Electricity):
An electricity back up room is set up to support the dialysis units and reprocessor
when out of electricity provision occurs, which could only last for the usage of 4-6
hours, approximately for one shift.
REPROCESSING ROOM
Adhering to the Haemodialysis Quality and Standards by the Ministry of Health
Malaysia, where dialysers are being reused, a separate dialyser reprocessing room
shall be available. Other requirements stated are:
Requirements by
Ministry of Health In Station 2
Malaysia
This room shall only Used dialyzers are cleansed here using the
be used for dialyser reprocessing machines. With a total of 3
reprocessing, storing machines, each disinfection period takes up
of reprocessed approximately 10 minutes for a thorough
dialysers and cleansing. At the end of each day the operator
Figure 44: Reprocessor
sterilant will sanitize each reprocessing station.
room
Building Services I [BLD 60403] Water Treatment for Domestic Water Supplies 35
DISPOSAL
Reverse osmosis is an important step in the water purification process. There are two types
of wastewater created from the water filtration process in haemodialysis centre. First is reject
water from the water reverse osmosis, which has not contact with the patient. Reject water
can be considered to be filtered water that has passed through RO System, but not through
the RO membrane. Second is post dialysis effluent, which is produced during the actual
dialysis process.
Thin film (TF) RO membrane that made of polyamide (PA) are the most common
type used in haemodialysis. These membrane are made with a thin, dense, semi-permeable
membrane over a thick porous substructure for strength and are spiral-wound permeate
collecting tube. The incoming water stream will split into two streams where one is purified
water that crosses the membrane and the other waste stream used to carry rejected solutes
to the drain. This is known as cross flow filtration.
Building Services I [BLD 60403] Water Treatment for Domestic Water Supplies 36
Firstly, these RO membrane will reject up to 95%-99% of dissolved inorganic
elements, such as salts, ions of metals, chemical and organic compounds which as greater
than a molecular weight of 200 Daltons (Da), including viruses, bacteria and endotoxins.
Hence, reject water is remarkably good water as it contain only small final traces of salts and
ions and lies well within all biochemical and bacteriological standards for portable water set
by the Association for the Advancement of Medical Instrumentation (AAMI). However, in
Station 2, St. John Ambulance Malaysia dialysis centre, they discard the reject water to
normal drain instead of reusing it as they have no storage tank to store the water. It does not
come into contact with the patient at any stage and therefore poses no infection risk and
pollution to the normal drain.
Building Services I [BLD 60403] Water Treatment for Domestic Water Supplies 37
As product of dialysis treatment, dialysis effluent, is very high risk water source
because the dialysis fluid is directly in contact with blood. In other words, it is a biological
waste product and may contain bacterial or viral particles from the patient. However, there is
no evidence that this poses a definite infective risk. In one study, dialysis wastewater was
analysed and compared to municipal, industry, Food and Agriculture Organization of the
United Nations (FAO) and World Health Organization (WHO) standards for wastewater used
for agricultural applications. Apart from an expected higher conductivity, the dialysis effluent
did not exceed FAO standards for biochemical oxygen demand or bacteria. Therefore, the
dialysis centre will uniformly drained the dialysate effluent and is uniformly diverted to the
sewerage where septic tanks are used. Addition of chemicals used in the disinfection
process would damage the bio flora essential in the normal function of the septic system
used by some patients. For these situations, they have construct an independent water
disposal pit for chemically tainted water during disinfection process whilst all other effluent
water is diverted to sewerage.
Building Services I [BLD 60403] Water Treatment for Domestic Water Supplies 38
6.2.5 QUALITY CONTROL & MAINTENANCE
The Food and Drug Administration (FDA) is responsible for the regulation of dialysis
water purification systems and they classify water systems, along with dialysis machines, as
Class II medical devices (FDA, 2011). Class II devices need diligent tracking of critical
components and a complaint investigation system in place. Class I devices include loosely
regulated items, band-aids whereas Class III are strictly regulated devices and require
tracking of all parts, like the high flux haemodialyzer.
Hence, water pre-treatment system and RO water plant require regular supervision,
maintenance and servicing. Each water pre-treatment system shall have a log book with
careful written records documenting every intervention, repair, servicing or maintenance
procedure. The log book should be kept in a convenient location, ideally near the equipment.
In Station 2, St. John Ambulance Malaysia haemodialysis centre, 4 equipment need to have
preventive maintenance every year; air-conditioner, generator, septic tank and water test.
The following preventive maintenance schedule are:
Service for air-conditioner is 3 times per year (4 months once)
Service for generator is 3 times per year (4 months once)
Service for septic tank is twice per year. (6 months once)
Service for water test is every month.
Building Services I [BLD 60403] Water Treatment for Domestic Water Supplies 39
Figure 51 & 52: Preventive maintenance/ calibration schedule & logging list
Every haemodialysis unit shall have written policies and procedures for the safe
operation of the water pre-treatment systems and RO water plant for quality control purpose.
The operation of the water pre-treatment system shall only be carried out by person who
have been trained and accredited.
Obtaining water samples for testing shall be from the appropriate location as detailed
in the operational policies and procedures from the dialysis unit. These policies and
procedures shall include information on how to collect the water sample, where the sample
is collected from, what the water sample is collected in and how the sample is maintained up
to the time it is tested.
Next, recording and trending results are also another quality control used in dialysis
centre. All water test results shall be recorded and trended over time. The trending result will
show if there is any slight changes of test results over time. The test results and trending
graphs should be maintained near the water pre-treatment system.
Building Services I [BLD 60403] Water Treatment for Domestic Water Supplies 40
There must be a third party involvement which is licensed or accredited as there is an
understanding of the responsibility and reporting structure required by the Health Service.
The sample is to be taken at the points where all haemodialysis equipment connects
to the distribution piping system. Samples for bacteriological testing should be assayed
within 30 minutes of collection, or to be immediately stored at a temperature between 1-5
and assayed within 24 hours of collection on a regular schedule. Whereas, endotoxin should
be measured 6 monthly. These test is apply to sampling at the point of delivery to
Building Services I [BLD 60403] Water Treatment for Domestic Water Supplies 42
haemodialysis equipment. The presence of endotoxin can be tested using the Limulus
Amebocyte Lysate (LAL) test.
However, when the test results exceed the action level, there should be a review of
the following procedures as the first step to isolate the potential problem. First, level of
bacteria exiting the RO machine. Second, product water distribution system disinfection
procedures. Lastly, examination of the distribution piping system for dead spots that may
contribute to bacterial contamination including possible contamination of bacteria filters if
they are installed in the distribution system. After the problems is find out, the correction
action will be undertaken in the area of the suspected cause for exceeding the action level.
Corrective action include cleaning and disinfection of RO membrane, disinfection of the
product water distribution system which including the entire loop, installation of an endotoxin
filter system in the RO water distribution system and/or increasing the frequency of
disinfection of existing bacteria filters, and need to make sure that the water hose on the
machine is being disinfected.
Residual testing:
This test is to determine that no residual of any chemical disinfection agent is
present. For water plant, adverse and abnormal readings may show that the condition of the
RO membrane requires interventional maintenance. The maintenance must be according to
the manufactures recommendations and may require chemical cleaning. Thus, the residual
testing is required to be undertaken at the completion of the maintenance. Moreover, dialysis
machine is also needed for residual testing. After performing a disinfection on the dialysis
machine with sodium hypochlorite (bleach), the machine shall be tested to ensure no
disinfectant remains in the machine.
Building Services I [BLD 60403] Water Treatment for Domestic Water Supplies 43
Figure 54 & 55: AAMI standard for water test in haemodialysis centre
Building Services I [BLD 60403] Water Treatment for Domestic Water Supplies 44
Figure 56 & 57: Certificate of Analysis
Building Services I [BLD 60403] Water Treatment for Domestic Water Supplies 45
not operating, and monitored daily to make sure it will not go into a regeneration cycle during
a patient treatment. The system should also be set to regenerate the resin beads often
enough to provide exchange ions for the calcium and magnesium.
6.2.7 ADVANTAGES
The quality of purified water is important in dialysis, where water makes up 99% of
the dialysate. The dialysis patients health is directly related to the water quality as their
blood being cleansed by dialysate every year. If the water used to make the dialysate is not
completely pure, impurities from the water in the dialysate can get into patients blood. Many
of these impurities can cause patient serious harm. If impure water is used during dialysis
treatment, a variety of things could happen:
Too much calcium or magnesium will cause nausea, severe headaches, muscle
weakness and low or high blood pressure.
Metals can cause various kind of symptoms such as liver damage, brain damage or
even death.
The chemicals that added to destroy bacteria will destroy red blood cells if they enter
the blood stream
Bacteria and endotoxin can cause infections and fever.
Building Services I [BLD 60403] Water Treatment for Domestic Water Supplies 46
Firstly, the advantage of RO system is the water in RO system is demineralized. Since
most mineral particles such as sodium, calcium, magnesium and iron are larger than water
molecules, so they are removed by the semi-permeable membrane of the RO system. Ultra-
pure water is the product water that have been purified by R.O system in dialysis centre. It is
the fluid that appeared to be free from particles, organic and inorganic contaminants.
Moreover, R.O water is eco-friendly as they do not produce or use any harmful
chemicals during the process. Furthermore, R.O system is expandable and space saving.
There are many sizes to choose from, so that people able to tailor their decision to fit their
needs.
Besides that, when comparing RO to Deionization filter (DI), which is alternative
water treatment system, RO will remove most of the bacteria. However, even though DI
coupled with ultrafiltration (UF) machine, it is still unable to remove low molecular weight
bacterial by-products, such as microcystins (toxins from blue-green algae), that are deadly to
patients. For this reason, when DI is employed, two tanks need to be set up in a series of
configuration, one as the worker, one as back-up. Furthermore, DI will exhaust and dump its
retained ions, therefore DI is not recommended for primary filtration for the water treatment
use with multiple patients. Hence, this is one of the reason why dialysis centre in Malaysia
used reverse osmosis system (R.O) instead of deionization filter (DI).
6.2.8 DISADVANTAGES
Figure 58: Pie chart for lifecycle cost of RO systems in haemodialysis centre
All gauges and flow meters should be within manufacturers specifications and the
readings should be recorded daily. Water quality (conductivity or total dissolved
solids) should be within normal limits for the area, and checked against an
independent device routinely and recorded at least daily.
Suggestion #3:
Reject water can be reused in gardens, lawns and landscaping, for toilet flushes as
well as other cleaning purpose works.RO system reject water can also be recycled
back through a closed loop system for re-presentation to the RO system, either with
or without ongoing mains water mixing and/or dilution. Practise of reusing or
Building Services I [BLD 60403] Water Treatment for Domestic Water Supplies 50
recycling reject water, as it is good water can save up a considerable amount of
water and leads to a minimum waste.
6.3 CONCLUSION
The quality of the dialysis fluid highly depends on their components, which is largely
comprise of treated water and concentrate and the way they are prepared and distributed.
As mentioned, water takes up a big part for dialysis fluid and it is obvious that it plays an
essential role in the chemical and microbial quality. Not to forget that the choice of water
treatment system is also crucial in ensuring that treated water meets the standard set by the
AAMI.
However, it should not be taken for granted that having an ideal selected type of
water treatment system means that all problems relating to water quality has been resolved.
It is significantly as important to have a proper water treatment system installed that
maintenance and monitoring of the quality control of the system is maintained throughout the
operation.
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If no proper amount of attention is given to maintain the water quality, no water
treatment system is good enough to cater the needs of the dialysis centre or any other
relevant operators. This responsibility is entrusted to the people managing such system.
With the innovations and improvements in water treatment processes, now it is make
possible to produce dialysis fluids of high level of chemical and microbial quality. And with
the advancement of technologies and experts in various field, it would be good to see more
improvements and attention given to the development of such system in the future, for the
health of the current patients as well as future users.
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7.0 LEARNING OUTCOME
Exploring this case study, we realized that treated water are essential to mankind,
even more to dialysis patient or similar users. We use, consume and waste water in a daily
basis. The amount of bacteria, viruses and contaminant are more than we could imagine. If
we neglect such existence, more harm will land on us. Hence, water treatment is an
essential step. As there as many types of water treatment, we should know and understand
each type more and choose wisely on which best suit our need or use.
In the end of the day, as we could not avoid using water, we should at least equipped
ourselves with the knowledge of the proper ways of treating water. This ensure that we
would get a clean and consumable water as in the end of the day, it is all for our own good,
safety and health.
To conclude, we have learnt that health is wealth and water treatment hallmarks it!
Building Services I [BLD 60403] Water Treatment for Domestic Water Supplies 53
8.0 REFERENCES
Aamiorg. (2017). AAMI Standards Philosophy and Strategy Key Elements. Retrieved 6
https://purifieradvisors.com/7-benefits-reverse-osmosis-systems/
Charleston water system. (2017). Water treatment process. Retrieved 6 July, 2017, from
http://www.charlestonwater.com/149/Water-Treatment
Coulliette&Arduino. (2017). Hemodialysis and Water Quality. Retrieved 6 July, 2017, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4596525/
Dialysis Water Pre-treatment for In-Centre and Satellite Haemodialysis Units in NSW: A Set
http://mylink.hnehealth.nsw.gov.au/pluginfile.php/33870/mod_page/content/1/Networ
ks_Streams_Groups/Leadership_group/WATERGuidelines_DialysisNSW_June2008.
https://www.fda.gov/ICECI/Inspections/InspectionGuides/InspectionTechnicalGuides/
Joe, S. (2017). How Does a Dialysis Machine Work. Retrieved 6 July, 2017, from
https://www.davita.com/treatment-options/hemodialysis/in-center-hemodialysis/how-
does-a-dialysis-machine-work?/t/5596
Johnson, D., Hawley, C., & Dheda, S. (2015). Water Treatment for Centre and Home-Based
hemodialysis/water-treatment-for-centre-and-home-based-haemodialysis
Building Services I [BLD 60403] Water Treatment for Domestic Water Supplies 54
John W MacD, A. (2015). Reusing and recycling dialysis reverse osmosis system reject
https://www.researchgate.net/publication/282346294_Reusing_and_recycling_dialysi
s_reverse_osmosis_system_reject_water
http://www.kiriwasco.co.ke/TreatmentProcess.html
Layman-Amato, R., Curtis, J., & Payne, G. M. (2013). Water Treatment for Hemodialysis: An
https://surveyortraining.cms.hhs.gov/Preceptor/PManual/ESRD/Resources/ESRD-
Monitor-Water-System.pdf
Ltd, A. P. (n.d.). Handbook for Reusing or Recycling Reverse Osmosis Reject Water from
http://waterportal.com.au/swf/images/swf-files/62r-2056-handbook.pdf
Nancy Hearn, C. (n.d.). Reverse Osmosis Water Health Advantages & Disadvantages.
Network, D. W. (2016). Water for dialysis A guide for in-centre, satellite and. Retrieved from
https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0007/306088/water-for-
dialysis-2016.pdf
Nicholas , A. , Ronco , C. & Levin , R.(2017). The Importance of Water Quality and
https://www.karger.com/Article/PDF/89430
Philip Andrysiak, BS, MBA, CHT; Philip M. Varughese, BS, CHT. (2002). DIALYSIS &
content/uploads/2016/02/Design-Requirements.pdf
Building Services I [BLD 60403] Water Treatment for Domestic Water Supplies 55
Pontoriero, G. (2003). The quality of dialysis water. Nephrology Dialysis Transplantation,
18(90007), pp.21vii-25.
renatron: 100 Series Dialyzer Reprocessing System. (2011). [ebook] pp.11-20. Available at:
http://www.medivators.com/sites/default/files/pdf/50090-733RevA.pdf.
https://www.espwaterproducts.com/reverse-osmosis-installation-guide/
Ringer21. (2010). Monitoring Your Dialysis Water Treatment System. Retrieved from
https://www.slideshare.net/ringer21/monitoring-your-dialysis-water-treatment-system
Water for dialysis: A guide for in-centre, satellite and home haemodialysis in NSW. (2016).
https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0007/306088/water-for-did
-2016.pdf.
http://www.science.uwaterloo.ca/~cchieh/cact/applychem/watertreatment.html
http://www.veoliawatertechnologies.co.uk/processwater/blog/water-treatment-for-
dialysis.htm
Water Treatment for Hemodialysis: Updated to Include the Latest AAMI Standards for
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9.0 APPENDICES
Figure 59:
From left to right;
Daphne Tan, Karen Lim, Madam Parameswary (interviewee; Centre Manager),
Loh Wei Ting, Lau Wan Yee, Lim Xiao Shi
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