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Pure water runs life! Choose Quality in PurityA.H.S. 2019

P I T D A ke-8Pertemuan Ilmiah Tahunanan Daerah ke 8

Ikatan Perawat Dialisis Jawa Timur

6-7 April 2019 Mercure Hotel, Surabaya

ManajemenPengelolaan Air Hemodialisis

di Fasilitas Pelayanan Kesehatan

Ardi H. Sudjadi





Regulasi Untuk Standart Kualitas

Skema WTP

Monitoring & Dokumentasi

GARIS BESAR PEMBELAJARAN DALAM SLIDE





STANDART AKREDITASI (1)





STANDART AKREDITASI (2)





REGULASI YANG ADA(1)

1





2






3






4

REGULASI YANG ADA





RAW WATER REPORT MUST BE CONSIDERED





REFERENSI – Kontaminan Air





Dialysis Unit

OtonomTank

Pre-Treatment

RO

(Treated water)

Reverse Osmosis

(RO)

(Pure water)

Post-Treatment

RO

(Pure water)

Distribution & loop system

SKEMA SEDERHANA WATER TREATMENT PLANT (WTP)

HospitalCentral /

Main Tank





GAMBARANAIR BAKU





CONTOH LOKASI Dialysis Unit Otonom Tank

HDFIRE SYS.

KEB. RT





Apa yang harus dimonitor pada tandon baku Otonom

Kualitas & Kuantitas

Apa yang harus dimonitor pada pre treatment RO ?

Fungsi removal sisa klor

Fungsi getting the soft water





Removal sisa klor menjadi penting karena :

Setiap tetes air yang mengalir dari keran rentan terhadap kontaminasi patogen (bakteri, virus, fungi, protozoa, dll).

Chlorination (menggunakan senyawa chlor),

gas klor (Cl2),

kalsium hipoklorit (Ca(OCl)2),

sodium hipoklorit (NaOCl)

klor dioksida (ClO2)

LAZIM DILAKUKAN

SISA KLOR

Removed / reduced

Reverse Osmosis





CARBON

Max. allowed ≤ 0,1 mg/l Cl2

HARMFULL FOR PATIENTS

Key note Monitor kualitas, setiap sebelum shift pasien dimulai Pastikan juga backwash berjalan sebagaimana mestinya

HD

In the 2001 AAMI RD62 standard, the maximum allowable contamination levels for chlorine were 0.5 mg/L for free chlorine and 0.1 mg/L for chloramines (AAMI, 2001). In the new standard, the maximum level is simply 0.1 mg/L for total chlorine.

Removal Cl2 effectiveness





Sisa klor diukur setelah flushing jaringan pipa dengan sodium hipoklorit (NaOCl)





SOFTENER

Max. allowed = see the RO manufacturing spec.

Key note Monitor kualitas, setiap min. 1-3 hari sekali Pastikan juga regenerasi berjalan sebagaimana mestinya Pastikan maintenance brine tank (pengecekan air & garam) dilakukan tiap hari.

Water softening effectiveness





Nilai kesadahan air pre-RO ↑↑

Fouling pada membran ROKapasitas produksi RO ↓↓Usia membran RO ↓↓

Proses regenerasi sudah tidak mumpuni

Perubahan kualitassecara tiba”

Water softening effectiveness





Key note Pastikan jam & hari pada head control menunjukkan waktu yang sesuai Ketahuilah pada jam berapakah proses backwash & regenerasi di set

MUST DO - Monitoring Backwash & Regeneration





Shf.1 Sign. Shf.2 Sign. Shf.3 Sign.

1OK / Need

POA

2OK / Need

POA

3OK / Need

POA

4OK / Need

POA

5OK / Need

POA

6OK / Need

POA

8OK / Need

POA

9OK / Need

POA

10OK / Need

POA

11OK / Need

POA

12OK / Need

POA

13OK / Need

POA

15OK / Need

POA

16OK / Need

POA

17OK / Need

POA

18OK / Need

POA

19OK / Need

POA

20OK / Need

POA

22OK / Need

POA

23OK / Need

POA

24OK / Need

POA

25OK / Need

POA

26OK / Need

POA

27OK / Need

POA

29OK / Need

POA

30OK / Need

POA

31OK / Need

POA

Water Treatment Plant Quality Control

Form. WTP-IHD 01

Total Chlorine Routine Sampling

Month DateSampling

Year

Threshold ≤ 0.1 mg/L

Status

Form. WTP-IHD 03

Time (hh:mm) Sign

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

DateBrine Tank


Adding salt pellets to brine tank

Monitoring records at Pre-Treatment

Form. WTP-IHD 02

1 OK / Need POA

2 OK / Need POA

3 OK / Need POA

4 OK / Need POA

5 OK / Need POA

6 OK / Need POA

7 OK / Need POA

8 OK / Need POA

9 OK / Need POA

10 OK / Need POA

11 OK / Need POA

12 OK / Need POA

13 OK / Need POA

14 OK / Need POA

15 OK / Need POA

16 OK / Need POA

17 OK / Need POA

18 OK / Need POA

19 OK / Need POA

20 OK / Need POA

21 OK / Need POA

22 OK / Need POA

23 OK / Need POA

24 OK / Need POA

25 OK / Need POA

26 OK / Need POA

27 OK / Need POA

28 OK / Need POA

29 OK / Need POA

30 OK / Need POA


Resume of Hardness TestingThreshold ≤ 17.12 mg/l CaCO3

No. Sampling Time Sign.Test Result

(mg/l)Status





Rejection ranges from approximately 90% to 99%

RO Membrane Performance




6-7 April 2019 Mercure Hotel, Surabaya RO Membrane Performance




6-7 April 2019 Mercure Hotel, Surabaya RO Membrane Performance

NOT GOOD &Difficult to monitor





Percent recovery of a large RO system isgenerally set between 50% to 75%

RO Membrane Performance





PEMERINTAH PROPINSI DAERAH TINGKAT I JAWA TIMUR

RUMAH SAKIT UMUM DAERAH DR. SOETOMO

INSTALASI HEMODIALISIS

Jl. Mayjen.Prof.Dr. Moestopo 6-8 Surabaya (60286)

Telp. (031) 501.2029, 550.1628 Telp./Fax : (031) 501.4353

From. WTP-IHD-03


Total Disolve Solids (TDS)

Mesin RO 1

Jam Feed Product % Rejection Jam Product Feed % Rejection

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

Instruction :

Sampling time: Randomized each shift

Remember :

% Rejection = [(TDS Feed-TDS Product)/(TDS Feed)] x 100%

2

0

1

8

Port sampling product value : See the TDS inline meter (at PPM)

Port sampling feed value : use the hand-held TDS meter into filtration tank port (at PPM)

Tahun

BulanTgl

Shift 1 Shift 2


Total Product Capacity

From. WTP-IHD-04

Jam PermeateConcen-

trate

%

Rec.Jam Permeate

Concen-

trate

%

Rec.Jam Permeate

Concen-

trate

%

Rec.

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

Instruction :

Sampling time: Randomized each day

Remember :

% Rec. = [(Permeate)/(Permeate + Concentrate)] x 100%

2

0

1

8

Port sampling permeate & concentrate value : See the inline meter indicator (at GPM)

RO-2Tahun

BulanTgl

RO-1 RO-3

Monitoring records at RO





ACARA / KEGIATAN LOKASI WAKTU PERSONIL

Nama TTD

Pengambilan sampling air,

Dari port : mesin RO 1-3

Untuk parameter :

kontaminan logam berat

Sampling akan diujikan ke

: Sucofindo, Surabaya.

Parameter yang ditunjukkan

tiap mesin RO pada saat

pengambilan sampel:

a. Mesin RO-1 SN: 100238

dengan TDS = 16 ppm,

%rejection = 94,48%,

suhu air = 30,40C

b. Mesin RO-2 SN: 98202



suhu air = 30,60C

c. Mesin RO-3 SN: 95390



suhu air = 30,40C

Gedung

Instalasi

Hemodialisis

Kamis,

12 Juli 2018

Jam :

15.30

Person In Charge (PT.SRU) 1. Yudha

2. Fajar Pengawas, Instalasi HD : 1. Saidin

2. Risky

Contaminants & heavy metal RO Water assay




6-7 April 2019 Mercure Hotel, Surabaya Di Gedung Inst. HD

Hasil air RO Hasil air RO Hasil air RO

RO-1 RO-2 RO-3

10012/FOBOAJ #) 00834/FOBOAL #) 00827/FOBOAL #) 00826/FOBOAL

Alumunium (Al) mg/l 0,16 nd nd nd 0,01

Antimony (Sb) mg/l <0.006 nd nd nd 0,006

Arsenic (As) mg/l <0.001 nd nd nd 0,005

Barium (Ba) mg/l 0,054 0,027 0,014 0,018 0,1

Calcium (Ca) mg/l 44 0,46 1,2 0,4 2

Fluoride (F) mg/l 0,0094 nd 0,12 nd 0,2

Cadmium (Cd) mg/l <0.003 nd nd nd 0,001

Potasium (K) mg/l 1,9 nd nd nd 8

Free chlorine (Cl2) mg/l 0,077 nd nd nd 0,5

Magnesium (Mg) mg/l 15,8 nd nd nd 4

Nitrate (NO3-N) mg/l 3,5 nd nd nd 2

Sodium (Na) mg/l 26,6 1,2 1,6 1,5 70

Argentum (Ag) mg/l <0.003 nd nd nd 0,005

Mercury (Hg) mg/l <0.001 nd nd nd 0,0002

Selenium (Se) mg/l <0.001 nd nd nd 0,09

Zinc (Zn) mg/l 0,0048 0,012 0,018 0,027 0,10

Sulphate (SO4) mg/l 27,5 nd nd nd 100

Copper (Cu) mg/l <0.003 nd nd nd 0,10

Lead (Pb) mg/l <0.004 nd nd nd 0,005

Total Chromium (Cr) mg/l <0.004 nd nd nd 0,014

#) Certificate number, issued date January 04, 2018 * nd = not detection

Rencana Tindak Lanjut :

Secara keseluruhan hasil uji kualitas air RO dengan parameter kontaminan logam berat telah memenuhi

standart dan aman bagi pelayanan HD .

Selanjutnya monitoring harian terhadap %rejection Reverse Osmosis wajib diperhatikan oleh tim teknis HD.

Note :

SN Mesin RO-1 : 100238



Tim Teknis HD , Tim ISL & Tim Vendor

Ttd.

PEMERINTAH PROPINSI DAERAH TINGKAT I JAWA TIMUR

RUMAH SAKIT UMUM DAERAH DR. SOETOMO

INSTALASI HEMODIALISIS

Parameter

Hasil air

bakuNilai

ambang

batas

Form Rekapitulasi Kualitas Air dengan Parameter Kontaminan Logam Berat

Satuan

Recording method of Contaminants & heavy metal RO Water assay





RO Trouble

Water leak

Pump malfunction

Membrane crack





UV lamp followed with ETRF





As the UV kills the bacteria, it may increase the level of endotoxin in the water as a result of the

destruction of the gram-negative bacteria (endotoxin producing) cell wall where endotoxins harbor.

To trap the endotoxin, UV should be followed by ultrafiltration

UV monitoring

UV is a low-pressure mercury vapor lamp enclosed in a transparent quartz

sleeve that emits a germicidal 254 nm wavelength,

UV is able to penetrate the cell wall of the bacterium and alter the DNA

to either kill it or render it unable to replicate.

The irradiator shall be equipped with a calibrated ultraviolet intensity and

activates a visual alarm that indicates the lamp needs to be replaced.

SEE THE LAMP INDICATOR





ETRF monitoring





Central Water TankRSDS

Ground Water Tank (GWT)Gedung Inst. HD

DRAIN / DIBUANG

TRUK TANGKI PDAM(jika ada gangguan

pasokan air)

PRE-TREATMENT SERIES-1(AUTO BACKWASH & REGENERATION)

FILTRATION TANK

RO-1

BackwashWaste water

2nd Floor Raw Water Tank

2nd Floor Raw Water Tank

BRINE TANK

BRINE TANK

1 2 3A 3B 4

RT = 70 M3

Firesystem = 43 M3

Dialysis = 27 M3

Tot. = 140 M3

1,3 M3

1,3 M3

BRINE TANK

BRINE TANK

1 2 3A 3B 4

PRE-TREATMENT SERIES-2(AUTO BACKWASH & REGENERATION)

1,3 M3

5

RO-25

RO-35

1,1 M3 1,1 M3

UVET

16 PORT MESIN HD

1ST FLOOR

UVET

UVET

UVPORT REUSE

(preparation stage)

1st F. 2nd F. 2nd F.

22 PORT MESIN HD

2nd FLOOR – 2B

21 PORT MESIN HD

2nd FLOOR – 2A

2nd F.

Loop1st F

Loop2A

Loop2B

LoopReuse

RO RejectWater

1 = Sand Filter

2 = Carbon Filter

3A & 3B = Softener Filter

4 = Pyrolox Filter

5 = Micron filter inlet RO

RO = Reverse Osmosis

UV = Ultraviolet Filter

ET = Endotoxin Filter

Black lines = Raw/tap water flow

Orange lines = Treated water flow

Blue lines = Denim water flow

Green lines = Loop water flow

Red lines = Waste water flow

Purple lines = Rejected RO water flow

TANDON PRODUK RO

TANDON PRODUK RO

WATER TREATMENT PLANT – INSTALASI HDMAP OF THE WATER TREATMENT FLOW

INSTALASI HEMODIALISIS – RSUD Dr. SOETOMOKEPALA,

NUNUK MARDIANA, dr., Sp.PD-KGH

CONTOHSkema WTP





A B

Max. Bacteria on port ≤ 200 CFU

Penentuan Port Sampling





Water sampling of bacteriology, endotoxin and heavy metal contaminants regularly performed by sanitarians of ISL





Contoh rekap dokumentasi





REFERENSI WAJIB





Pergantian Resin & Pengurasan Brine Tank Pergantian ETRF




6-7 April 2019 Mercure Hotel, Surabaya Pump

Type of post RO pump Type of pre RO pump





Ruangan control kualitas air HD

manajemen pengelolaan air hemodialisis di fasilitas...

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