FEED PUMPS ×2
100 L/min each — City Water In
CHECK: Feed Pressure
✅ PASS: ≥20 psi
❌ FAIL: <20 psi
ACTION FAIL: Check city water supply, clean inlet screen. If <15 psi = SHUTDOWN
ONLINE CHLORINE MONITOR
Total Chlorine — City Water
CHECK: Reading (mV)
✅ PASS: 500–900 mV (≈0.8–1.5 mg/L)
❌ FAIL: >1000 mV or <400 mV
ACTION FAIL: Verify with DPD test strip. If >2.0 mg/L, call city water. Calibrate monthly.
AUTO SAND FILTER
50 GAL — Removes Turbidity
CHECK: ΔP (IN − OUT)
✅ PASS: <15 psi
❌ FAIL: ≥25 psi
ACTION FAIL: Backwash NOW. If ΔP remains ≥25 psi after backwash = SHUTDOWN — replace media.
5µ SEDIMENT FILTER
Slim Housing — Protects RO
CHECK: ΔP (IN − OUT)
✅ PASS: <15 psi
❌ FAIL: ≥25 psi
ACTION FAIL: Change cartridge NOW. Log date. SHUTDOWN if no spare.
CARBON TANK #1
50 GAL — EBCT 5.9 min @ 32 L/min
CHECK: Chlorine OUT after Tank 1
✅ PASS: <0.1 mg/L
❌ FAIL: ≥0.1 mg/L
ACTION FAIL: Tank 1 exhausted. Switch to Tank 2. Replace carbon within 24 hrs. Continue operation with Tank 2.
CARBON TANK #2 — FINAL DEFENSE
50 GAL — EBCT 5.9 min @ 32 L/min
CHECK: Chlorine OUT after Tank 2
✅ PASS: 0.0 mg/L ONLY
🚫 FAIL: >0.0 mg/L
🚨 IMMEDIATE SHUTDOWN: Stop dialysis. Both tanks exhausted. NO patients can be connected. Call contractor. Notify MOH.
DUPLEX SOFTENER
Removes Hardness — Protects RO
CHECK: Hardness OUT
✅ PASS: 0–1 gpg
❌ FAIL: ≥1 gpg
ACTION FAIL: Regenerate NOW. If ≥3 gpg = SHUTDOWN — will foul RO membranes within hours.
RO SYSTEM — 4 MEMBRANES
Feed: 20 L/min | Product: 8 L/min | Reject: 12 L/min
CHECK: Recovery % (Product ÷ Feed)
✅ PASS: 35–50% (Target 40%)
❌ FAIL: <25% ⚠️ or >60%
FAIL <25%: Leak/waste — check O-rings, connections.
FAIL >60%: SHUTDOWN — membrane fouling. CIP within 4 hrs.
RO CONDUCTIVITY (TDS)
Product Water Purity
CHECK: Conductivity
✅ PASS: <25 µS/cm
❌ FAIL: ≥25 µS/cm
ACTION FAIL: Membrane leak — check O-rings. If >50 µS/cm = SHUTDOWN. Divert to drain. >5 increase in 1 day = ALERT
VENTILATION FILTER
0.2µ Hydrophobic — Tank Air Inlet
CHECK: Filter Condition
✅ PASS: Clean, dry, within expiry
❌ FAIL: Dirty, wet, or expired
ACTION FAIL: Replace IMMEDIATELY. Prevents airborne bacteria from entering storage tank. Replace q6mo.
STORAGE TANK
88,000 L — 1 Day Reserve Minimum
CHECK: Water Level (3-Float System)
✅ PASS: >2.0 m (Green/Yellow)
❌ FAIL: <1.5 m (Red — ALARM)
ACTION FAIL (Red): RO not keeping up. Check RO flow, pumps. If <1.0 m = SHUTDOWN — 88,000 L = ~5 days supply.
LOOP PUMPS ×2
100 L/min each = 26.4 gpm
CHECK: Loop Velocity
✅ PASS: >3.0 ft/sec (Yours: 9.8)
❌ FAIL: <3.0 ft/sec
ACTION FAIL: Check pump speed, valves, filters. If <2.0 ft/sec = SHUTDOWN — biofilm risk in distribution loop.
UV LAMP — 12 GAL
254 nm — Bacteria Kill
CHECK: UV Intensity / Dose
✅ PASS: >30 mJ/cm²
❌ FAIL: <30 mJ/cm²
ACTION FAIL: Clean quartz sleeve. If still <30 mJ/cm² = SHUTDOWN. Replace lamp (max 9000 hrs / 12 months). Log hours.
0.3µ BIOLOGICAL FILTER — FINAL BARRIER
Absolute Rated — Removes Endotoxin
CHECK: ΔP (IN − OUT)
✅ PASS: <15 psi
🚫 FAIL: ≥25 psi
🚨 ACTION FAIL: Change cartridge IMMEDIATELY. SHUTDOWN if no spare. This is the last defense before patients. Endotoxin breakthrough = Mass Casualty.
DIALYSIS MACHINE
Dialysate Mix — Fresenius / B Braun / Nipro
CHECK: Conductivity & Alarms
✅ PASS: 13.5–14.5 mS/cm — Alarms functional
❌ FAIL: Outside range or alarm test fails
ACTION FAIL: DO NOT USE. Call biomedical team. Verify concentrate batch. Conductivity CANNOT detect ion substitution (K⁺/Na⁺ errors).
ACID CONCENTRATE
5L Jug — A11 or Similar
CHECK: Batch Number & Level
✅ PASS: Correct batch, jug full
❌ FAIL: Empty jug or wrong batch
ACTION FAIL (Empty): DO NOT USE. Water-only dialysis causes hemolysis. Replace with correct batch. Verify with second nurse.
BICARBONATE CONCENTRATE
5L Jug or Cartridge — NaHCO₃
CHECK: Level & Expiry
✅ PASS: Full, not expired
❌ FAIL: Empty or expired
ACTION FAIL (Empty): DO NOT USE. Without bicarbonate, patient will develop metabolic acidosis. Replace immediately.
POWER SUPPLY
UPS / Generator — Critical Infrastructure
⚠️ VULNERABILITY:
Most water treatment units have NO UPS or generator.
🚨 CRITICAL: If power fails during regeneration — regeneration will NOT happen. Carbon and softener remain exhausted. Check water quality BEFORE starting dialysis after any power interruption.
SAMPLE PORTS
Stainless Steel — Sanitary
LOCATIONS:
• After Carbon Tank #1 🏛️ MOH
• After Carbon Tank #2 🏛️ MOH
• After RO Product Daily
• Loop Return Monthly
PROTOCOL: Flush port for 30 seconds before sampling. Use sterile container. Label with date, time, and location. Record in logbook.
PRESSURE GAUGES
0–100 psi — Liquid Filled
CHECK: All Filter + RO + Loop Gauges
✅ PASS: Needle steady, no fluctuation
❌ FAIL: Fluctuating, stuck, or zero
ACTION FAIL: Replace gauge IMMEDIATELY. Cannot monitor system without accurate pressure readings. SHUTDOWN if critical gauges fail.
FLOW METERS
RO Permeate + Reject — GPM / LPM
CHECK: Flow Rates
✅ PASS: Stable, within expected range
❌ FAIL: Sudden change > 10%
ACTION FAIL: Check for leaks, blockages, or pump issues. Recovery % calculation depends on accurate flow readings. SHUTDOWN if cannot verify.
TDS / CONDUCTIVITY METER
Handheld — Calibrated
CHECK: Calibration & Function
✅ PASS: Calibrated, reads standards correctly
❌ FAIL: Out of calibration or not reading
ACTION FAIL: Calibrate with standard solution. If still failing — DO NOT USE. Replace meter. Record calibration in logbook.
CHLORINE TEST KIT
DPD — 0–5 mg/L Range
CHECK: Reagent Expiry & Function
✅ PASS: Reagents within expiry, clear color change
❌ FAIL: Expired reagents or no color change
ACTION FAIL: Replace reagents IMMEDIATELY. DO NOT rely on expired reagents for patient safety decisions. MUST read 0.0 after Carbon Tank #2.
HARDNESS TEST KIT
Titration — 0–20 gpg
CHECK: Reagent Expiry & Function
✅ PASS: Reagents within expiry, clear endpoint
❌ FAIL: Expired reagents or no color change
ACTION FAIL: Replace reagents. Hardness MUST be <1 gpg after softener. High hardness = RO scaling = membrane failure.
ENDOTOXIN TESTING (LAL)
Limulus Amebocyte Lysate — EU/mL
CHECK: Test Results
✅ PASS: <0.25 EU/mL
🚫 FAIL: ≥0.25 EU/mL
🚨 ACTION FAIL: IMMEDIATE INVESTIGATION. If ≥0.5 EU/mL = SHUTDOWN. Endotoxin breakthrough = Mass Casualty. Notify MOH and infection control.
MEMBRANE CLEANING SKID
CIP — Acid/Alkaline Cleaning
SCHEDULE:
✅ Routine: Every 6 months
⚠️ Trigger: ΔP > 15% increase
🚫 Urgent: ΔP > 25% increase
PROCEDURE: Use approved cleaning chemicals. Follow manufacturer instructions. Flush thoroughly after cleaning. Document all cleaning cycles in logbook.
SANITIZATION PUMP
Heat/Chemical — Loop Disinfection
SCHEDULE:
✅ Routine: Monthly — ISO 23500
⚠️ After: Any positive bacterial culture
🚫 Urgent: After endotoxin detection
PROCEDURE: Use approved sanitization protocol. Heat: >80°C for 30 min. Chemical: Follow manufacturer instructions. Document all sanitizations.
LOGBOOK / EXCEL
MOH Requirement — All Daily Readings
REQUIRED RECORDS:
• TDS/Conductivity — Daily
• Chlorine — Daily
• Hardness — Weekly
• Endotoxin — Quarterly
• EBCT Calculation — Monthly
• CIP/Sanitization — Each Event
📌 REMINDER: MOH requires all records to be available for inspection. If it is not documented, it did not happen.
EMERGENCY SHUTDOWN
IMMEDIATE ACTION — MASS CASUALTY
TRIGGERS:
🚫 Chlorine > 0.0 mg/L after Tank #2
🚫 Endotoxin ≥0.5 EU/mL
🚫 Two patients with unexplained chills
🚫 RO product TDS > 50 µS/cm
🚨 IMMEDIATE SHUTDOWN:
1. Disconnect ALL patients
2. Do NOT return blood
3. Call Code Red — Mass Casualty
4. Notify MOH and biomedical team
BIOFILM PREVENTION
Distribution Loop — Continuous Circulation
KEY REQUIREMENTS:
✅ Continuous circulation (no stagnant water)
✅ Loop velocity > 3.0 ft/sec
✅ No dead legs
✅ Regular sanitization — Monthly
⚠️ REMINDER: Biofilm can rupture without warning — releasing endotoxin. Continuous circulation and regular sanitization are non-negotiable.
DEAD LEG INSPECTION
Distribution Loop — No Stagnant Water
WHAT TO CHECK:
✅ No capped or unused branches
✅ All valves are operational
✅ Sample ports flush before use
❌ Any dead leg > 6 diameters in length
ACTION FAIL: Dead legs = stagnant water = biofilm = endotoxin. ELIMINATE all dead legs immediately. Redesign loop if necessary.
BACKUP WATER SUPPLY
Emergency — RO Failure / City Water Cut
REQUIREMENTS:
✅ 1 day reserve in storage tank (88,000 L)
⚠️ Alternative water source identified
⚠️ Transportation plan for emergency supply
ACTION IF RESERVE LOW: Reduce dialysis schedule. Prioritize unstable patients. Contact backup supplier. Do NOT connect patients if water quality is uncertain.