Bs final report-fianls

Table of content
Acknowledgement
1.0 Introduction ………………………………………………………………………………
2.0 Water Treatment Process ……………………………………………………………..
3.0 Importance of Water Treatment ………………………………………………………
4.0 Type of Water Treatment in Domestic ………………………………………………
5.0 Installation Process …………………………………………………………………….
6.0 Case Study
6.1 St. John Ambulance Malaysia ………………………….………………………
6.2 Water Treatment System in Haemodialysis Centre
6.2.1 Importance & Standard ………………………….……………………
6.2.2 Reverse Osmosis System in Haemodialysis ………………………
6.2.3 Design Consideration ………………………….……………………..
6.2.4 Components & Process ………………………….…………………..
6.2.5 Quality Control & Maintenance ………………………………………
6.2.6 Water Quality Testing ………………………….……………………..
6.2.7 Advantages ………………………….…………………………………
6.2.8 Disadvantages ………………………….……………………………..
6.2.9 Possible Problems & Suggestions ………………………………….
6.3 Conclusion ………………………….………………………….…………………
7.0 Learning Outcome ………………………….………………………….……………….
8.0 References ………………………….………………………….…………………………
9.0 Appendices ………………………….………………………….………………………..
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10 – 15
16 – 17
18 – 20
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23 – 36
37 – 38
39 – 43
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Building Services I [BLD 60403]Water Treatmentfor 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.

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.

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.
Figure 1. Water treatment process. (Kiriwasco, 2013)
Coagulation/flocculation: Liquid aluminium sulphate (alum), polymer and sometimes lime
and carbon dioxide are added to untreated water (raw water) during coagulation. This
process causes small particles to stick to one another, forming larger particles .Groups of dirt
particles stick together to form larger, heavier particles called flocs which are easier to
remove by settling or filtration.
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.
Corrosion control: pH is maintained by adding alkaline substances to reduce corrosion in
the distribution system and the plumbing in your home or business.

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 one’s 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 human’s 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.

4.0 TYPES OF WATERTREATMENT 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
Figure 2: Water softener.
Water hardness is demonstrated by scale in water heaters or on plumbing fixtures,
by soap deposits on dishes and fabrics, and by soap scum in sinks and bathtubs.
Water can become “hard” as water passes through the atmosphere in the form of rain, snow
or fog, as it picks up minerals along with gaseous and bacterial impurities. And, because
water is the universal solvent, it picks up even more impurities when in ponds, lakes, and
even rivers, as it permeates into the underground water table.
Water hardness is measured in grains per gallon (GPG). Water can be softened with
detergents, chemicals or other compounds that can be very expensive. The most commonly
used method is ion exchange softening which is relatively inexpensive and provides the
luxury of using more natural types of cleaning products for household chores and personal
care.

2. Activated Carbon Filters
Figure 3: Activated Carbon Filter
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.

3. Sediment Filters
Figure 4: Sediment filter.
Sediment filters without or coupled with pre-aeration are often used to reduce the
concentrations of iron. The water oxidized physically or chemically prior to filtration increases
the efficacy of the filters. The pore size of the filters generally ranges from 0.2 to 2.0 microns.
Reportedly up to 25 mg/L can be effectively treated with filtration. Most sources indicate a
concentration up to 10 mg/L is about the most that can be treated. At lower iron
concentrations (e.g. 3 to 5 mg/L or less) it is possible to use an ion exchange system. The
addition of a chemical oxidant such as chlorine prior to the filter will improve the efficiency of
the filter.
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.

5. Reverse Osmosis Water Filter System
Figure 5: Reverse osmosis process.
When a compartment containing a dilute solution is connected to another
compartment containing a concentrated solution by a semipermeable membrane, water
molecules move from the dilute solution to concentrated solution. This phenomenon is
called osmosis. Pig bladders are natural semipermeable membranes. As the water
molecules migrate through the semipermeable membrane, water level in the solution will
increase until the (osmotic) pressure prevents a net migration of water molecules in one
direction. A pressure equivalent to the height difference is called the osmotic pressure.
By applying pressure in the higher concentration solution, water molecules migrate
from a high concentration solution to a low concentration solution. This method is
called reverse osmosis water filter system.

5.0 INSTALLATIONPROCESS
5.1 REVERSE OSMOSIS UNIT AT HOMES
All plumbing must be completed in accordance with state and local plumbing codes.
Step 1.Installation Location
Find a suitable location where the system can be installed. Make sure there is
sufficient space under the counter for proper installation. Locate the “cold” water shut
off valve and sink drainpipe.
Step 2. Closing Cold Water Valve
Shut off the “cold” water supply under the sink or the location where the system will
be installed. If the existing “cold” water valve is inoperable, the water supply to the
house must be shut off. Then, relieve the line pressure by opening the “cold” water
faucet.
Step 3. Connecting To Cold Water Line
There are several options when connecting the reverse osmosis unit to the cold-
water source. They are:
 Saddle valve (Standard)
 Ez adapter (Optional)
Figure 6: Saddle-Tapping Valve Assembly

Step 4. Drain Line Connection:
CAUTION: If the drain line pipe is badly corroded replace it.
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.
Step 5. Faucet Installation
Installation procedures for Porcelain, Enamel, Ceramic on Metal, or Cast Iron:
Precautions must be taken to penetrate the porcelain through to the metal base and
prevent chipping or scratching.
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".

Installation procedures for stainless steel sinks
Procedures:
 Mark the center with center punch for the 1/4" pilot hole.
 Drill the pilot hole.
 Continue to enlarge hole with larger size drill bit until it is 1/2".
 Clean up sharp edges.
Mounting the Faucet
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.
Angle Stop Valve and Tubing Installation
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.
Figure 8: Angle Stop Valve Assembly
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.

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.
Figure 9: Drain Saddle Valve Assembly
Initial Tubing Connections
For convenience on under sink installations it may be advisable to
complete under sink tubing connections at this time.
RO Component Installation
Install RO membrane O-ring end first, carbon prefilter(s) and sediment
pre filter in vertical mounted housings. Be sure RO Membrane is
pushed into Membrane housing as far as it will go. It is recommended
that filters and membranes be handled with clean or gloved hands.

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.
Step 7. System hook up.
Remove any red caps from the end of the tubing. There may be water present in
these lines if the system was wet tested at the factory, so keep a towel handy to wipe
up any water.
 Connect the units orange feed water line to the saddle valve or EZ adapter
installed on the cold water line. Use the plastic delrin sleeve that are provided
in the installation kit and discard any brass ferrules that may have been
provided.
 Connect the black line from the unit directly to the drain clamp assembly. If
an air gap faucet is used see instruction listed under air gap faucet installation
instructions.
 Connect the green line to the RO water storage tank.
 Connect the blue line from the unit to the faucet.
Note: color of lines may vary from manufacturer to manufacturer – we have attempted to
use industry standard colors in describing the system hook up procedures.
Note: Make sure all inserts, sleeves and ferrules provided in the installation kit
are used.

Step 8. Starting Up the System
Turn off the storage tank ball valve, this will ensure no water can enter the tank.
Slowly turn on the cold water supply valve to the sink. If you have not already done
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.

6.0 CASE STUDY
Water Treatment System in Haemodialysis Centre
For this case study, we had an interview with Madam Parameswary, the centre
manager of Station 2, Haemodialysis located in Klang. “If water is not safe, the patients will
be in danger. Hence, water treatment is very important in dialysis centre.” (Parameswary,
personal interview, June 21st
, 2017)
6.1 ST. JOHN AMBULANCE MALAYSIA
Figure 10: SJAM logo
St. John Ambulance of Malaysia or SJAM is a Malaysian-based, non-government
organization dedicated to the work of humanity and charity by providing first aid and
community services to the public. SJAM has been rendering first aid services and home
nursing assistance to needy in public and private events as well as helping out when
disaster occurs throughout the country.
Figure 11: Certification of ISO 9001:2008
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.
Figure 12: Signage.
In 2000, Station 2 was launched to cope with the increasing number of patients
seeking for dialysis treatment within Klang area. Now, they are able to cater the need of
16 patients in one go.
Figure 13: Exterior view of Station 2
Name of building: Pusat Haemodialysis SJAM-Kawasan Pantai Selangor (Station 2)
Launched Year: 2000
Operation: Since 12 August 2002
Contact: +60333745005
Address: No.100 Persiaran Raja Muda Musa, Klang, 41100, Selangor

6.2 WATER TREATMENT SYSTEM IN HAEMODIALYSIS CENTRE
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 patient’s 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.
Figure 14: Comparing water consumption of average population to dialysis patient.
An average person drinks between 10-14
litres of fluid per week but
an average dialysis patient is exposed to
about 300 or more litres of fluid per week

Haemodialysis treatment involves the use of an artificial kidney, known as a
haemodialyser to remove waste and chemicals from the patient’s body, usually a 3 to 5
hours treatment session, 3 times per week. The treatment involve using a dialysate, a
continuously produced blend of treated water and a concentrated solution containing
electrolytes, buffer and glucose that pulls the wastes and extra fluid through its semi-
permeable membrane out of the patient’s 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.
According to the Haemodialysis Quality and Standards by the Ministry of Health
Malaysia, it is stated that:
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.

6.2.1.2 STANDARD/ GUIDELINE
The Association for the Advancement of Medical Instrumentation (AAMI) is a unique
alliance of professionals and organizations dedicated to the understanding and beneficial
use of medical device technology founded in 1965. AAMI members include health care
institutions, research and teaching facilities, government agencies, manufacturers, test
houses, trade associations and individual health care professionals.
AAMI has since updated the recommendations, specifically for the microbiological
methods and standards for haemodialysis concentrates, water for haemodialysis, water
treatment and related therapies, and dialysis fluids. Comparisons of these regulatory and
recommended standards are shown in Table1.

6.2.2 REVERSE OSMOSIS IN HAEMODIALYSIS
Figure 15: Reverse osmosis conceptual diagram.
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.

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:
 Choice of equipment for power and water efficiency/conservation.
 Room that houses the water treatment system shall be located in an area where
noise and disruption is minimized when installing, maintaining and operating the RO
water plant.
 Consideration of installation designs that utilise water conservation, e.g. dual-pass
RO systems or the use of reject water in sterilising departments or storage tanks for
irrigation or sanitation flushing.
 The maximum water flow, including expected future growth in the number of patients
to be treated. Consider the maximum disinfection water flow.
 Average water flow per day also including expected future growth.
 There shall be adequate ventilation to prevent over-heating.
 Pressure gauge shall be installed before and after each component to monitor
fouling of the components.
 Drainage required.
 All water treatment components and equipment shall be clearly labelled.
 The weight of the operational RO water plant and the ability of the floor to safely
support that weight.
 Water quality monitoring systems.
 Facilities to safely service and maintain the central water plant (CWP).
 RO water distribution loop path, material, length and insulation requirements.
 RO water distribution loop outlet types, number of, consideration of spare and testing
outlets.
 All centres shall have a water treatment system that delivers water quality that meets
the ISO 23500:2011 Standards.

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.
Figure 16: Pre-filter raw water tank
FEED WATER CONTROL
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
Temperature blending valve
The temperature blending valve mixes hot and cold water to achieve a RO membrane
standard temperature around 25° C. Every drop of 1° C below 25° C, the quantity of product
water is reduced by approximately 3% and if the temperature exceeds 33° C, the RO
membrane may be damaged. Hence, a hot and cold water mixing valve is present to
regulate the temperature to 25° C.

WATER TREATMENT SYSTEM PROCESS FOR HAEMODIALYSIS
Figure 17: Water Treatment Process in Station 2 SJAM

COMPONENTS & FUNCTIONS
Figure 18
Raw Water Tank Pre-Filter
▪ Known as pre-filter as it contains raw water
▪ Direct enter of water from municipal
▪ Able to store up to 450 galloons
▪ Water level consider safe at 300 gallons, but to be alert
when it gets lower than that
Figure 19
Rocket Filter
▪ Filters sedimentation from pre-filter raw water tank to
post-filter raw water tank
▪ Flush to backwash weekly
Figure 20
Raw Water Tank Post Filter
▪ Stores and directs water from rocket filter to be treated

Figure 21:
From left to right:
auto sand filter,
auto carbon filter,
auto softener filter
Figure 22 & 23:
Blue brine tank
connecting to softener
Auto Sand Filter
▪ Feed water passes through layers ranging from
gravel to sand that physically and gradually trap
suspended particles
▪ Tiers constructed from different sized elements to
trap and remove particulates thoroughly
▪ Filter and settle sediments, mud, sand and floating
particles
▪ Pressure gauges on the inlet and outlet of tank
monitor pressure changes
Auto Carbon Filter
▪ Remove chlorine, chloramine, odour, colour
▪ To remove chlorine and chloramine additives from
feed water
▪ Solutes, colour and odour can be removed when
they diffuses from the water into the pores of the
carbon
.
Auto Softener Filter
▪ Softeners turn hard water into “soft” water where
calcium and magnesium is exchanged with sodium
▪ Resin beads in softener releases 2 Na+ ions for
every 1 Ca or Mg ions captured
▪ NaCl formed will not deposit on the RO membranes
and will be rejected to the drain
Brine Tank
▪ Softener needs regenerating with concentrated
sodium chloride solution (brine) before exhausting
its resin capacity
▪ Salt is added weekly and stir continuously until it
becomes concentrated solution

Figure 24
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
and rejected solutes enters another pipe to be drained
▪ Rejects dissolved inorganic elements (eg: ions &
chemicals) and organics (eg: bacteria & endotoxin) to
the drain
Figure 25
R.O Systems
 Two sets, namely R.O 1 and R.O 2 are present to cater
the needs of approximately 16 patients
Figure 26
Figure 27
R.O Treated Water Storage Tank
▪ Initially used to store water but now no longer being
used as bacteria might accumulate in the stored water
▪ Clean product water is now pumped straight to
reprocessor or dialysis machines
UV Sterilizer
▪ Protects against bacterial contamination

Figure 28
R.O Water Pump #1 #2
▪ To pump water to pipes of machines and reprocessor for
disinfection
▪ Supply up to 120-130litres per shift for a patient
Figure 29
Reprocessor
▪ Used dialysers are not dispose of immediately as some
can be reuse after proper cleaning
▪ Through reprocessor, used dialysers are thoroughly
washed for next time usage for the same patient
Figure 30
Pressure gauges
▪ Measures the inlet water supply, pump, reject water and
product water pressures

DISTRIBUTIONSYSTEM
Also referred to as the RO water loop, RO distribution systems can be grouped into two
categories:
Figure 31: Distribution system.
1. A direct feed system
Directly delivers the product water from the RO water plant to the product water loop
for distribution. Unused product water can be recirculated back to the input of the RO
unit for conservation reasons.
Figure 32, 33 & 34: RO water pumps product directly to machines
2. An indirect feed system
Stores the product water in a storage tank prior to distribution through the loop.
Water that is not used within the distribution system is returned to the storage tank.
Figure 35: RO treated water storage tank

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:
Pros of direct feed system Cons of indirect feed system
Reduced risk of bacterial contamination Higher risk of bacterial contamination
Dialysis water is constantly monitored &
sent to drain if unclean enough
Poor tank design may lead to stagnation
and contamination if inadequate air filter
Easier disinfection Disinfection & maintenance is extremely
difficult
Figure 36: Ultraviolet sterilizer
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.

PRODUCT WATER
Product water is then directed to either reprocessor or dialysis machine for their
respective usage.
Figure 37, 38 & 39: Pipes connecting product water
Dialysis machine
Figure 40
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
checked.
Reprocessor
Figure 41
The reprocessing machine disinfect used dialyzers to prepare
them for further usage. Calibrated every morning with the total
cell volume calibration cell, used dialysers are then cleansed of
residual blood as well as blood products by rinsing them with RO
water.

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.
Figure 42 & 43: Process of disinfection of dialyzers

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
Malaysia
In Station 2
This room shall only
be used for dialyser
reprocessing, storing
of reprocessed
dialysers and
sterilant Figure 44: Reprocessor
room
Used dialyzers are cleansed here using the
reprocessing machines. With a total of 3
machines, each disinfection period takes up
approximately 10 minutes for a thorough
cleansing. At the end of each day the operator
will sanitize each reprocessing station.
Adequate and
efficient ventilation
shall be in place to
reduce inhalation
risk
Figure 45: Air conditioned
room
The reprocessing room is well ventilated with air
conditioner, providing a cool area that is out of
direct sunlight.
Reprocessed dialyzers or dialyzers awaiting for
reprocessing should not be exposed to freezing
temperature or sources of heat.

DISPOSAL
Figure 46: Flow chart of water disposal in haemodialysis centre
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.
Figure 47: Structure of reverse osmosis membrane

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.
Figure 48: Reverse Osmosis module
Figure 49: Drainage of haemodialysis centre

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.
Figure 50: Dialysis machine

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.
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.
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.
Figure 53: Signed by third party which is licensed or accredited

6.2.6 WATER QUALITY TESTING
Monitoring Water Quality
The water purification system is a multiple layer system designed to progressively
purify water at each step. The resulting dialysis water needs to meet the minimum criteria for
chemical and microbiological characteristics that form the basis of the definition for standard
and ultrapure quality dialysis water. Association for the Advancement of Medical
Instrumentation (AAMI) is one of the guideline specifying the minimum allowable standards
for water quality.
Monitoring the feed water:
The first test that is done is monitoring the feed water. A chemical analysis of feed
water should be performed periodically so that the dialysis centre is aware of the chemical
composition, and assure that the water treatment system is designed to be able to reduce
those contaminants to levels identified by AAMI. The feed water analysis can be taken
before it enters any part of the water treatment system such as a sink that near the water
treatment room as long as it has not been treated. The samples are sent to a qualified lab
that has the capability of analyzing them by the correct methodology and to the levels
specified by AAMI. The feed water can be analyzed at least four times a year so that the
dialysis centre will know any seasonal variations, which are often present.
Monitoring the product water:
The product water also need to be analyzed periodically so that the water that are
used for dialysis meets AAMI standards for chemical contamination. The sample should also
be sent to a qualified lab that has the capability to analyzing them by correct methodology.
Quality testing of the product water is needed to be done at least quarterly. Samples for
product water chemical analysis should be drawn from a sample port immediately after the
RO system. When reviewing the results, the dialysis centre need to ensure that there are no
contaminant levels that exceed AAMI standards.
The dialysis centre will compare the results with past testing results and do a trend
analysis to determine if any levels are increasing to provide an advance knowledge about a
potential degradation of the water treatment system, or changes in the supply water. This
monitor will have an alarm in the treatment room that alerts the dialysis centre if the water
quality degrades. If any contaminants results exceed AAMI standards, a trend analysis
should be done to see if there is any increase in the contaminant level.

Monitoring microbiological contamination:
Microbiological contamination of water is a serious health concern for patients that
are on dialysis. If there is a high levels of bacteria or endotoxin in the water, it will probably
harm patients by causing pyrogenic reactions or even systematic infections if a dialyzer
membrane ruptures. Therefore, it is essential to monitor both bacteria and endotoxin levels
in the water used for dialysis and dialyzer reprocessing. The level of bacteria in water shall
not exceed the AMMI standard of 100 colony forming units/ml (CFU/ml) with an action level
of 50 CFU/ml. In other hand, the level of endotoxin in water must not exceed the AMMI
standards of 0.25 Endotoxin Units per Millilitre (EU/ml) with an action level of 0.12 EU/ml.
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
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.
Figure 54 & 55: AAMI standard for water test in haemodialysis centre

Monitoring Dialysis Water Treatment Equipment
Monitoring back flow prevention device:
It is required by building codes that dialysis water treatment equipment be connected
to the source water through a Backflow Prevention Device (RP). The screen on the RP
device can be plugged up thus reducing the water flow through it. Therefore, RP device
needs to be monitored for fouling of the internal screen. It is done by monitoring the pressure
going into and out of the device. There is normally a reduction in pressure across an RP
device, often is 20 pounds per square inch (PSI). If the pressure difference between pre and
post RP device increases by 10 PSI from baseline, the internal screen should be cleaned, or
the RP device may need servicing. RP device must also be checked for proper function at
least annually by someone who has been properly trained and certified.
Figure 56 & 57: Certificate of Analysis
Monitoring the booster pump:
In order to maintain minimum pressure and flow to the treatment system, booster
pumps are often used on the feed water line. The on and off cycle of booster pumps are
controlled by either a pressure switch or flow switch, which turns the pump on when the
pressure drops below a specific set point, and turn off once the pressure recovers to the
baseline. So, once the proper set points are established, the pump should be monitored
periodically to ensure its proper functioning and that the booster pump cycles on and off as
needed.

Monitoring the water softener:
There are several things need to be monitor in water softener to assure that the
water softener will perform appropriately. First, total hardness of post softener. It is
measured in Grains per Gallon (GPG) or Parts per Million (PPM) where the AAMI standards
is recommends a limit of 1 GPG or 17.2 PPM. Second, the pressure drop should be
monitored before and after the softener. The device may require back flushing if the
pressure drop changes by more than 10 PSI from baseline. A breakdown of the resin can
occur which can also cause increased pressure drops. Next, salt level in the brine tank.
There should always have sufficient amount of salt in the tank to allow the resin beads to be
regenerated by the softener. Lastly, regeneration timer. The timer should be set to activate
when the facility is 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.
Monitoring ultraviolet irradiator:
Regular maintenance for the UV irradiation device includes continuous monitoring of
radiant energy output that activates an audible and visual alarm, routing cleaning of the
quartz sleeve and replacing the lamp at least annually, as recommended by the
manufacturer.
Monitoring drain system
There are several considerations in maintaining the drain lines in the dialysis
facilities. First, requirement of minimum 1-inch air gap between the equipment drain line and
the building drain pipes. This air gaps is to prevent the possibility of sewage being drawn into
the machine, or direct contact with the drain line if the sewer gets backed up. Second,
because dialysis drains will attract fruit flies, which create infection control issues within the
unit. If this happens, some have reported that periodically pouring or straight household
bleach or commercial gel product down the drains will resolve this problem.

6.2.7 ADVANTAGES
The quality of purified water is important in dialysis, where water makes up 99% of
the dialysate. The dialysis patient’s 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 patient’s 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.
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
Extensive life cycle cost of dialysis water treatment
The costs involved in running a water treatment system for haemodialysis centre
include capital and maintenance costs. The price for a water treatment system unit may vary
from depending on specific requirements and design, for example the length and type of the
water piping required (heat resistant piping is necessary if heat disinfection is used).
Operation costs occupied the largest part of the lifecycle cost for water treatment in
dialysis. From expenditures in the supply of water and electricity, recurrent costs in
purchasing consumables goods also takes part on it. Recurrent costs include the purchase
of consumables including particle filters, salt tablets for the water softener, chemical sterilant
and test-strips, as well as the renewal of the RO membrane which needs to be replaced
every 5 years or so.
For the service and maintenance part, inspection of reprocessing machine by certain
technician on regular basis spend a part of it. Besides, it may include the repairing for
defection in particular systems to preserve the efficiency of the system as well as the
expenditures for quality control measures like regular water cultures, laboratory analysis for
water chemical contaminants, and endotoxin assays.
Figure 58: Pie chart for lifecycle cost of RO systems in haemodialysis centre

6.2.9 POSSIBLE PROBLEMS & SUGGESTIONS
Problem #1: Bacteria growth
Risk of chemical contamination is mainly due to the primary pollution from municipal
water whereas microbiological contaminant, mainly on the bacterial growth in the
water treatment and distribution system. Research found that stagnant water,
especially those stored in water storage tank which contains large amount of water
that no longer have chlorine or chloramine to prevent microbial growth. A number of
multicentre studies have reported that 7–35% of water samples have bacterial growth
as well as rising endotoxin levels. These results of multicentre studies indicate that
the microbial quality of dialysis fluids is still a too often neglected problem, particularly
as there is evidence of a possible relationship between dialysis fluid contamination
and long-term morbidity.
Suggestion #1: Storage tank with specific design consideration
The tanks should be designed to prevent the growth of bacteria by having a conical
or bowl-shaped bottom for complete emptying, and have a tight fitting lid that is
vented to air through a hydrophobic 0.2 µm air filter to prevent microbes from
entering the tank. The tank should be designed for easy frequent disinfection and
rinse with an internal spray mechanism. Storage tanks shall be made of inert
materials that do not leach contaminants into the purified water. UV bulbs are
installed to kill microorganism.

Problem #2: Improper design of RO system
Water quality could be greatly affected if RO systems are not designed appropriately.
The amount of dissolved solids in water produced by reverse osmosis is
approximately a constant percentage of those in the feed water. For example, when
the feed water contains 300 ppm total dissolved solids (TDS), the product water may
have 15 to 30 ppm (95% and 90% rejection ratio respectively). A RO system design
is based on a certain range of feed water TDS, the percentage of rejection and
percentage of recovery desired. For a given system, the higher the percentage of
recovery or the lower the percentage of rejection, the poorer the quality of product
water becomes.
Suggestion #2: AAMI chemical analysis
An AAMI chemical analysis shall be performed at least once a year to validate the
removal of contaminants by the water treatment system. The AAMI sample should be
drawn after all the components, on the most distal portion of the distribution loop or
loop. The system must operate within the AAMI parameters at all times, so it is
suggested to test quarterly. An additional AAMI analysis should be done if the
percent rejection falls below 90% and/or the water quality degrades below a
predetermined set parameter (dependent upon location) especially if it is unable to
be recovered through cleaning or repair.
When a new RO system is put in place or when RO membranes are replaced, an
AAMI chemical analysis must be completed. If a predetermined set point for water
quality is violated, the product water should divert to drain in order to avoid delivering
patients unsafe water. The medical director should be notified to determine whether
to continue treatments.
All gauges and flow meters should be within manufacturer’s 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.

Problem #3: High wastage of treated water
When treated water does not meet the required standard, it would automatically be
regard as reject water. Such water can be stored in a tank or be disposed of. In the
centre, these reject water are discard off. Reject water are remarkably good water as
it contains only small traces of salts and ions which fits the standard for portable
water set by the AAMI, does not come into contact with the patient yet and hence,
are free from infection risk.
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
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.
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.

7.0 LEARNING OUTCOME
After almost a month of research, we came to an understanding that teamwork co-
operation is essential for any success for group work. We find it challenging to gather
information and to understand the content that includes extensive technical terms relevant to
the water treatment. However, it was a pleasant experience to learn something new and
acquire some skills to research, analyse and evaluate materials which are relevant to our
study. Each of us is fully participating in this report and did well on our job. Without any one
of us, this tasks would not have been achievable.
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!

8.0 REFERENCES
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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
Figure 60: Name card

Bs final report-fianls

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