manajemen pengelolaan air hemodialisis di fasilitas...
TRANSCRIPT
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
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Regulasi Untuk Standart Kualitas
Skema WTP
Monitoring & Dokumentasi
GARIS BESAR PEMBELAJARAN DALAM SLIDE
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Pure water runs life! Choose Quality in PurityA.H.S. 2019
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STANDART AKREDITASI (1)
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STANDART AKREDITASI (2)
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REGULASI YANG ADA(1)
1
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2
REGULASI YANG ADA(2)
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3
REGULASI YANG ADA(3)
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4
REGULASI YANG ADA
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RAW WATER REPORT MUST BE CONSIDERED
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REFERENSI – Kontaminan Air
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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
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GAMBARANAIR BAKU
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CONTOH LOKASI Dialysis Unit Otonom Tank
HDFIRE SYS.
KEB. RT
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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
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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
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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
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Sisa klor diukur setelah flushing jaringan pipa dengan sodium hipoklorit (NaOCl)
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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
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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
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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
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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
Water Treatment Plant Quality Control
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
Water Treatment Plant Quality Control
Resume of Hardness TestingThreshold ≤ 17.12 mg/l CaCO3
No. Sampling Time Sign.Test Result
(mg/l)Status
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Rejection ranges from approximately 90% to 99%
RO Membrane Performance
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NOT GOOD &Difficult to monitor
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Percent recovery of a large RO system isgenerally set between 50% to 75%
RO Membrane Performance
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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
Water Treatment Plant Quality Control
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
Water Treatment Plant Quality Control
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
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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
dengan TDS = 20 ppm,
%rejection = 93,10%,
suhu air = 30,60C
c. Mesin RO-3 SN: 95390
dengan TDS = 11 ppm,
%rejection = 96,20%,
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
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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
SN Mesin RO-2 : 98202
SN Mesin RO-3 : 95390
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
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RO Trouble
Water leak
Pump malfunction
Membrane crack
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UV lamp followed with ETRF
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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
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ETRF monitoring
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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
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A B
Max. Bacteria on port ≤ 200 CFU
Penentuan Port Sampling
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Water sampling of bacteriology, endotoxin and heavy metal contaminants regularly performed by sanitarians of ISL
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Contoh rekap dokumentasi
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REFERENSI WAJIB
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Pergantian Resin & Pengurasan Brine Tank Pergantian ETRF
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Type of post RO pump Type of pre RO pump
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Ruangan control kualitas air HD