Dialysis Water: Monitoring the quality for hemodialysis and dialysis fluids

Dialysis water is one of the vital component for patient care. There is no denying the fact that drinking water allows the liquid to be processed through the gut and liver, where contaminants are inactivated or removed before absorption into the blood. But when it comes to dialysis water/dialysis fluid, water comes in direct contact with patient’s blood instead of the gut. This impeccably defines the difference and significance of dialysis fluid simultaneously.

To keep dialysis water quality intact, recommendations and international standards are available for the guidance of maximum allowable concentration of contaminants.

Maximum allowable concentration of Microbial Contaminants:

The presence of microbial contamination contributes to the development of biofilm, which in later stage is difficult to remove and results in the release of bacteria and bacterial fragments. These fragments in turn pose serious threat to the patient’s health if appropriate measures are not actualized.

Hence, the maximum allowable concentration as per standard requirements for dialysis water is less than 100 CFU/ml and for Endotoxin it’s less than 0.25 EU/ml. It’s pertinent to mention here that Endotoxins are the major component of outer cell wall of bacteria that are capable of causing severe infection, may lead to organ failure and even death if suitable measures are not taken.

The frequency of microbial testing:

Contaminant	Frequency	Maximum recommended concentration
Microbial Count	Monthly	<100 CFU/ml ( Action Level > 50 CFU/ml)
Endotoxins		0.25 EU/ml ( Action Level 0.125 EU/ml)

BS EN ISO 23500:2015 states there is no requirement to test for bacterial growth or endotoxins when the hemodialysis system is fitted with endotoxin retentive filters that are operated according to the manufacturer’s instructions, unless the manufacturer requires such tests to be performed.

Maximum allowable concentration of Chemical Contaminants:

Various chemicals have been clearly shown to be toxic to dialysis patients at concentrations that are not necessarily toxic to the general population. Those chemicals include aluminum, copper, chloramines, fluoride, nitrate, sulfate, and zinc. Organic chemicals have not been identified as toxic to hemodialysis patients because they are removed through reverse osmosis and carbon adsorption.

Following is the list of maximum allowable concentrations of chemical contaminants in dialysis water for which monitoring is mandatory:

Chemical Contaminant	Maximum recommended concentration (mg/l=ppm)
Aluminium	0.01
Calcium	2 (0.05mmol/l)
Copper	0.1
Fluoride	0.2
Magnesium	4 (0.15mmol/l)
Nitrate (as N)	2 (equates to 9 mg/l NO3
Potassium	8 (0.2mmol/l
Sodium	70 (3.0mmol/l
All of the above chemical contaminants when indicated should be tested initially every 3 months and are mandatory for the monitoring.
Arsenic	0.005
Cadmium	0.001
Chromium	0.014
Lead	0.005
Mercury	0.0002
Sulphate	100
Above group of contaminants for which the drinking water limit is 2 to 5 times the recommended limit for dialysis. In water treated by reverse osmosis, these contaminants will only exceed the limits if they occur at relatively high levels in the water supplied to the unit. These contaminants can be omitted from routine tests if data is available to show that the levels in the water supplied to the unit rarely exceed the limit. Such data is generally reviewed on an annual basis.
Barium	0.1
Beryllium	0.0004
Silver	0.005
Thallium	0.002
Zinc	0.1
The final group of contaminants (barium, beryllium, silver, thallium, tin and zinc) of trace elements are not considered to occur in levels that give cause for concern and, if low levels are present, they are removed effectively by reverse osmosis. Testing is only required if there is evidence of high levels in the local water supply (zinc, for example, can be introduced in the pipework or silver, present if the hospital water supply is treated with silver containing compounds to minimize the presence of Legionella bacteria).  If testing for trace elements is not available, compliance may be demonstrated by compliance with standards for potable water as defined by the WHO or local regulations. If neither of these options is available, compliance can be met through a reverse osmosis system with a rejection of >90 % based on conductivity, resistivity, or TDS.

 References

1. BS EN ISO 13959; 2015:Water for haemodialysis and related therapies

2.European Pharmacopoeia, 8 th ed. Monograph 1167:Haemodialysis solutions, concentrates, water for diluting. European Pharmacopoeia Commission 2014

3. Poli D, Pavone L, Tansinda P, Goldoni M, Tagliavini D, David S, Mutti A, FranchiniI. Organic contamination in dialysis water: trichloroethylene as a model compound. Nephrol Dial Transplant 2006 Jun; 21(6):1618-1625

4. The Water Supply (Water Quality) (England and Wales) Regulations 2000.Statutory Instrument No. 3184.Prescribed concentrations and values .http://www.dwi.gov.uk/regs/si3184/3184.htm#sch1 and http://dwi.defra.gov.uk/stakeholders/legislation/wqregs2007cons.pdf.

5. BS EN ISO 26722; 2015:Water treatment equipment for haemodialysis and related therapies

6. BS EN ISO 23500; 2015: Guidance for the preparation and quality management of fluids for haemodialysis and related therapies

7. JCI 7th Edition 

Arsenic in Drinking Water: Fundamental element of life is threatened by 12th most abundant element

 Arsenic is said to be the 12^th most significant semi-metallic element of the earth crust and commonly found in the atmosphere, soils, rocks, organisms and natural waters. The presence of arsenic in the environment is also associated with anthropogenic (man-made) activities. Arsenic can combine with other elements to form inorganic and organic arsenic compounds.

Acceptable Level of Arsenic in Drinking Water

No doubt, access to clean drinking water is among important indicators determined by the World Health Organization (WHO). SDG-6, one of the UN’s goals claims the same. Hence, various international and national organizations have set up the maximum permissible value of arsenic in drinking water.

The maximum acceptable levels of dissolved arsenic in drinking water are 0.01mg/l which is 10 ppb according to the World Health Organization and the United States Environmental Protection Agency, respectively. However several other countries including Pakistan accepts 0.05mg/l which is 50 ppb. The PSQCA, PEQS and NSDWQ have recommended a limit of 50 ppb for arsenic concentration in drinking water. Following table is showing permissible limits of Arsenic in drinking water:

Water Quality Parameter	Standards	Unit	Permissible Limits
Arsenic	WHO	mg/l or ppm	0.01 mg/l (0.01*1000 = 10 ppb)
	US-EPA guidelines
	IBWA
	FDA
	PEQS 2016 for Drinking Water		<0.05 mg/l (0.05*1000 = 50 ppb)
	PSQCA
	NSDWQ
	IWQS

 The US EPA is of the view that continuous exposure to arsenic over 0.05mg/l results in various health implications. There are number of places in Pakistan where concentration of Arsenic is more than 0.05 mg/l. The US EPA further suggested that by lowering the arsenic standard from 50 to 10 ppb could reduce the probability of multiple diseases.

Arsenic in drinking water and its health implications

In recent decades, water body resources got polluted owing to heavy metals has become one of the serious environmental problems. Humans come into contact with it because it percolates into groundwater from rocks and sediments. Being soluble in water, it exists in ionic forms and affects the humans who consume arsenic contaminated water. Its effects are severe and long-lasting.

It has been said that receiving arsenic through the water and long term exposure can lead to severe health ramifications such as cancer, skin disorders, lung infection, high blood pressure, cardiovascular issues and many other health implications are there in a row. As per International Agency for Research on Cancer (IARC), Arsenic may affect internal organs by impairing their normal functioning without causing any visible external symptoms.

                                 Twelfth abundant element in the nature

Making quality of water denature

A great threat for a living creature

Need to sort out the literature

To save us all from the menace of this miniature 

                                                                            (Haider)

Unfortunately, Pakistan is one of those countries where most of the ground water is contaminated with Arsenic.

ABBREVIATIONS

§  WHO – World Health Organization

§  US EPA – United States Environment Protection Agency

§  PSQCA – Pakistan Standard Quality Control Authority

§  IBWA – International Bottled Water Association Standard

§  FDA – Food & Drug Administration

§  PEQS – Punjab Environmental Quality Standards

§  NSDWQ – National Standard for Drinking Water Quality

§  IWQS – Indian Water Quality Standards

§  IARO – International Agency for Research in Oncology

 

References

1.       'Alarmingly high' levels of arsenic in Pakistan's ground water - BBC News

2.       Zhang L, Ye X, Feng H, et al. 2007. Heavy metal contamination in western Xiamen Bay sediments and its vicinity, China. Mar Pollut Bull 54:974–82. doi:10.1016/j.marpolbul.2007.02.010.

3.       Mohammadi AA, Yousefi M, and Mahvi AH. 2017. Fluoride concentration level in rural area in Poldasht city and daily fluoride intake based on drinking water consumption with temperature. Data Brief 13:12–315. doi:10.1016/j.dib.2017.05.045.

4.       Khan, M.M.H., Sakauchi, F., Sonoda, T., Washio,M., & Muri, M. (2003). Magnitude of Arsenic Toxicity in Tube-well Drinking water in Bangladesh and its adverse effects on human health including cancer, Evidence from the view of literature. Jour Asian Pacific cancer, 4, 7-14.

5.       Kaltreider, R.C., Davis, M.A., Lariviere, P. J., & Hamilton, W. J. (2001). Arsenic Alters the Function of the Glucocorticoid Receptor as a Transcription factor. Journal of Environ Health Perspect, 109, 245–25.

6.       Guha Mazumder, D.N. (2004). Health Hazard caused by chronic arsenic toxicity in West Bengal. Proceedings: Workshop on Medical Geology (IGCP-454), Special Publications No. 83, Geological Survey of India.

7.       Gupta, A.B. and Gupta, S.K. (2004). Recent advances in fluorosis and defluoridaton with special reference to Rajasthan. Proceedings Workshop on Medical Geology, IGCP – 454. Special Publication No. 83, Geological Survey of India.

8.       Analytical Methods for Drinking Water Advances in Sampling and Analysis

Tricky Questions - Spill Management in Healthcare Facilities

WHAT IS SPILL? 

An unintentional or accidental fall, flow or runout of something can be termed as Spill. In Hospitals, these spills include chemicals, hazardous material, drug, blood and other bodily fluids. 

WHAT ARE THE COMMON KINDS OF SPILLS IN THE HEALTHCARE FACILITIES? 

There are four common or major kinds of spills such as: 

Biological Spills – Blood and other bodily fluids, culture of micro-organisms and other infectious materials. 

Chemical Spills – formalin, xylene and other acid, bases and drugs 

Mercury Spills – B.P Apparatus & thermometer mostly but mercury compounds are also used in preservatives and reagents. 

Cytotoxic Spills – cytotoxic drugs and medicines 

HOW SPILLS INTERACT WITH HUMAN BODY?
Harmful materials such as bacteria, viruses and other small organisms, fumes and vapors and inappropriate drug or medicine can enter in to the body by four ways such as: 

• 1.     Inhalation (breathing)
• 2.      Ingestion (swallowing)
• 3.      Absorption (through skin)
• 4.      Injection

WHAT ARE THE RISKS ASSOCIATED WITH THESE SPILLS?

• ·       They may have serious health consequences for instance; microorganism (bacteria, viruses) may gradually impact internal organs badly.
• ·       Mercury beads and its fumes can disrupt nervous system.
• ·       Chemicals and their vapors may cause skin & eye irritation depending upon their properties and nature.
• ·   Cytotoxic drugs (Cancerous drugs) are highly toxic to cells that may lead to adverse effects during exposure. 

WHAT IS THE ROLE OF SAFETY COORDINATOR IN THE EVENT OF A SPILL?

Assess nature of spill and adopt safety measures accordingly:

• ·         Stop the source of spill
• ·         Place caution sign or cordon off the area
• ·         Wear appropriate PPEs from spill kit
• ·         Use appropriate spill items to tackle spill such as absorbent pad etc.
• ·         Dispose of contaminated material including PPE in waste bags (Yellow & Red) or sharp container
• ·         Wash Area or disinfect area through housekeeping staff
• ·         Wash hands
• ·         Re-stock spill kit item

WHAT TO DO IF SAFETY COORDINATOR IS NOT AROUND DURING SPILL?

In this particular scenario, one must stop the source of spill, cordon off the area to avoid exposure and announce code yellow.

WHAT IS MEANT BY MINOR OR MAJOR SPILLS?

Spills that can be triggered through spill kits and without spill kits are termed as minor spill whereas spills that are unmanageable or cannot be tackled through spill kits are major spills. Hence, code yellow is announced for major spills or whenever concerned safety coordinator is not around.

WHAT TO DO IN TERMS OF EXPOSURE?

Try to reach nearby emergency facility such as eyewash bottle, eyewash station and emergency shower depending upon the severity of exposure. If problem still persists, visit EAR or employee health clinic as per need.

WHAT IS THE QUANTITY OF DISINFECTANT (SODIUM HYPOCHLORITE) SHOULD BE USED TO DISINFECT THE AREA?

In the guidelines, its mentioned 2gm/liter for sodium hypochlorite for all others except biological spill that is 100gm/liter.  Remember, the main purpose is to protect yourself and people in the surrounding from the exposure. It’s the minimum quantity and fluctuation in it is acceptable because it’s not a dose to be given to the patient. 

WHAT IS CODE YELLOW?

CODE YELLOW refers to major spills that can be radioactive, gas leakage, hazardous material or chemical spills. However, when safety coordinator is not around then code yellow may be announced.

WHEN CODE YELLOW SHOULD BE ANNOUCED?

In case of spill, one should stop the source of spill, cordon off the area and then inform departmental safety coordinator. He will take rest of the measures.

WHO RESPONDS WHEN CODE YELLOW IS ANNOUNCED?

Team to respond in case of CODE YELLOW:

• ·         Firefighting team because chemical may have flammable characteristics
• ·         Engineering & Maintenance Department (EMD) team to stop the flow, to cut off ignition source and to shut off valve.
• ·         Housekeeping for final cleaning

WHAT IS MEANT BY MSDS?

A Material Safety Data Sheet (MSDS) is a document that contains information on the potential hazards (health, fire, reactivity and environmental) and how to work safely with the hazardous materials. Hence, it’s mandatory to keep MSDS file near hazardous materials.

WHAT IS THE USE OF EYEWASH BOTTLE?

Eyewash bottle provides immediate flushing, consists of distilled water and used to clean, refresh & soothe eyes when exposed to chemicals and hazardous materials. 

                            

Remember Safety is more important than Convenience

Roles & Responsibilities of Safety Coordinators in Peshawar - Do it the Safe way & Do it the Right way

Safety Coordinators play significant role in order to ensure safe and secure environment for their staff and patients. They are responsible to ensure compliance of all the guidelines in order to reduce work related injury. Following are the roles and responsibilities of safety coordinators: 

                    

1	Facility Inspection  Rounds Participate in Facility Inspection/Environmental Rounds and ensures follow-up on observation/improvement opportunities
2	Risk Assessment Active role in departmental Risk Assessment at least annually. Maintain close liaison with Facilities Safety team during risk assessment and share all the identified risks. Ensure display of PCRA before and during renovation and construction activities within the department.
3	Departmental FMS Trainings & FMS Quiz Arrange and conduct trainings on FMS within department and maintain record/attendance in hard form or in TMS: FMS Quiz – 100% Fire Quiz – 100%
4	Knowledge of Fire & Awareness of Firefighting Equipment Knowledge of RACE & PASS Must be aware of locations of nearest firefighting equipment, fire exit, evacuation plan, evacuation routes followed by assembly points. Monitor inspections of departmental equipment as per requirement. Ensure corridors and exit points free from obstructions. Intimate Security in case of any ambiguity in the maps, routes etc.
5	Knowledge of Utilities Knowledge of  Electrical DB location & handling  Knowledge of location of Oxygen Shut off valves  All the oxygen cylinders must be clamped or in trolleys, shouldn’t be left unattended
6	Knowledge of Hazmat Ensure Hazardous Material Inventory followed by MSDS is updated on HIS and same record is maintained in hard form (blue file). Ensure staff knowledge about hazardous material labels/symbols. Staff knows about chemicals followed by MSDS, which are used in their respective area. Staff education is mandatory regarding MSDS
7	Knowledge of Spill & Spill Kit Knowledge of role during spill. Ensure availability of spill kits where hazardous materials/chemicals are placed and it should be easily accessible. Knowledge of spill kit item and its location  Ensure spill kit has all the relevant items available Frequent opening of spill kit for training or checking of spill kit items especially disinfectant. For more info, please refer to: 1.        Multi Purpose: Tricky Questions - Spill Management in Healthcare Facilities (multipurpose15.blogspot.com) 2.        Multi Purpose: Spill Management in Hospitals and Healthcare Facilities (multipurpose15.blogspot.com)
8	Personal Protective Equipment (PPEs) PPEs are available, in use where required and are in good condition. Ensure PPEs availability and usage as per MSDS when chemicals are used.
9	Emergency facilities and Eyewash Must ensure that Emergency facilities such as eyewash bottles, eyewash stations & showers are operational, their labels are uniformed and logs are maintained.
10	Departmental Incident Participate in Incident Investigation and responsible to raise QIO.
11	Knowledge of Emergency Codes In case of CODE RED (Fire): Liaison with \ Security regarding fire incident/ issue Control and direct all fire prevention efforts till the arrival of firefighting team. Assist firefighting team and make report of any missing staff members in assembly area after head counting. In Case of  Spill: Stop the source of the spill  Cordon of the area and take measures to reduce the likelihood of exposure according to spill management guidelines.  For major spills, CODE YELLOW is announced at extension 2500. In case of Bomb  & Terrorist threat: Record as much information as possible on the Bomb Threat Checklist then announce CODE BLACK at 2700. In case of Child Abduction: Call security at 2700 and / or exchange for announcement of CODE PINK and provide relevant information.   (For more details: https://multipurpose15.blogspot.com/2021/01/hospital-emergency-codes-codes-code.html )
12	Utilities Failure In case of Utilities Failure – Power Outage, Medical gases Outage or Water Failure: Notify shift supervisor/EMD. Determine the impact of utilities failure on patient care Check backup system
13	Waste Management Ensure appropriate segregation of hazardous waste as per Waste Management Programme. Ensure display of  disposal guidelines where different color bins are placed. Impart knowledge to other staff members.
14	Preventive Maintenance   Ensure that PM or PPM (Periodic Preventive Maintenance) of all utilities and medical equipment is done before due date.
15	Close Liaison with Facilities Safety    Maintain close liaison with Facilities Safety in case of any confusion while implementing any of these guidelines.

    

    Roles and Responsibilities will be updated as per need. To ensure compliance, these roles

    may be displayed in the respective area of safety coordinators. 

Remember Safety is more important than Convenience