NN&I - May 2010
Facility Management 50 Nephrology News & Issues May 2010www.nephronline.com a profound impact on water quality. Undoubtedly, these advances are wel-come news to dialysis providers who are charged with the responsibility to operate the water systems to produce acceptable water quality at the low -est possible cost. Each week 340,000 patients in the United States undergo treatments; for these patients, water is literally their lifeblood. The potential danger of microbial contamination to dialysis patients can -not be overstated. An individual receiv -ing three dialysis treatments a week is exposed to approximately 95 gallons of water; a healthy person is exposed to only about four gallons per week. On average, dialysis patients are exposed to an average person's equivalent of a lifetime of water in three years. The increased level of water expo-sure comes from the dialysate solu- tion, which is 90% water. Dialysate solution is the suspension required for patients who suffer from end-stage renal disease. Because a patient's blood is directly exposed to the solution, even the smallest concentration of con -taminants could result in the transfer of a significant level of toxins to the patient's system. This poses a serious risk to patients whose already dimin -ished kidney function leaves their body incapable of filtering and excreting any water-borne toxic substances in their urine. Therefore, they are exposed to higher levels of contamination than a person with healthy kidney function, making them highly susceptible to infection and illness. New trends in bacteria controlThe solution to the potentially dan -gerous problem of water contamina -tion is relatively simple. In order to both maximize the effectiveness of dialysis treatments and reduce the risk of infection from water-borne con -taminants, the water used in the pro- cess must be as pure as possible. The water purification process controls the microbiological organisms in final treated water and reduces the amount of microbiological matter exposed to patients. It stands to reason that the greater the water purity, the lower the risk of infection. With purification in mind, three sig -nificant trends have recently emerged that have greatly impacted water qual-ity: the use of hot water (80\260C) to sani-tize the reverse osmosis (RO) and loop; the use of a more sanitary design of the water treatment system; and the use of Teflon components in distribution systems. Each of these plays a role in ensuring that water quality approaches the high purity quality that has already become standard in Europe. The good news is that none of these choices involve a significantly higher cost to implement. In some cases the capital cost can have an offsetting cost in terms of maintenance and labor. Heat Sanitization Most notable among these advances is the use of hot water to sanitize RO machines, distribution loops, and other components. During heat sanitization, equipment is disinfected by applying heat at 80-85\260C. If this sounds familiar, it should. Pasteurization, as it is more commonly known, has been around since the 1850s, and is widely used in the production of pharmaceutical-grade water. This process has rapid-ly gained acceptance with respect to dialysis machines. The process can be performed automatically, making more frequent (i.e., nightly) sanitization pos -sible. Second, using heat is more cost-effective than chemical sanitization. Third, the process is much more envi-ronmentally friendly than the chemical process. Fourth, and finally, heat saniti-zation is less time-consuming, allowing sanitized equipment to be returned to service more quickly. More Sanitary Design New Centers for Medicare & Medicaid Services (CMS) guidelines for dialysis facilities, called the Conditions for Coverage, were updated and made more stringent in October 2008 for the first time since 1976. Since imple-mentation, the new CMS Interpretive Guidelines have created greater aware -ness of the vital role water plays in a dialysis patient's life. Bacteria control is at the forefront of actions that man-ufacturers and clinics are addressing with various initiatives in order to be in compliance with CMS. Bacteria control is accomplished by reducing and/or eliminating con-ditions that can promote bacteria growth. With the trend to harmoni -zation of water quality with United States Pharmacopeia (USP) standards, a greater awareness of the use of more sanitary designs and components has taken place. Under USP, pharmaceu-tical and health care companies are required to produce a higher grade of water for the manufacture of many products that do not have such a criti-cal role, like the water used in dialysis.So how is this higher standard accomplished? Clinics can achieve greater bacteria control and move closer to pharmaceutical-quality wat-er by using sanitary components, eliminating stagnant and dead leg conditions, keeping water moving, reducing the use of threaded con -nections, using more stainless steel and/or more sanitary plastic mate-rials. Clinics that have incorporated these upgrades have seen a significant increase in their microbiological con -trol, which should encourage more clinics to follow their example. Teflon loop components Traditionally, clinics have used PVC piping materials in constructing a dis-tribution loop. Although PVC was con-sidered adequate in the past, current thinking is that PVC is not ideal for tighter bacteria control and it limits the type and frequency of sanitants that can be used. Many clinics are now installing loops made of a fluoropoly -mer-like Teflon to give them an addi- Water Facility Manag(NEW).indd 50 4/19/10 10:10:27 AM
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