HD-WT-004 · Water System Failure Emergency Plan (UPDATED)

Emergency Response to Water Treatment System Failure

Policy HD-WT-004 · Hemodialysis Unit + Biomedical + Hospital Administration

Effective June 25, 2026 Review June 25, 2027 Replaces all previous

1 Purpose

To establish immediate actions to protect patient safety during central water system failure including RO failure, chlorine breakthrough, bacterial contamination, or power loss, per AAMI 23500, CMS, and MOH-Jordan 2023.

2 Scope

Applies to all RNs, technicians, biomedical staff, medical director, nursing admin, and hospital administrator on call. Covers central RO failure, loop contamination, power loss, and chemical breakthrough.

3 Definitions

Category 1 Failure Cl2 >0.5 mg/L OR bacteria >200 CFU/mL OR no RO water – STOP ALL HD IMMEDIATELY Category 2 Failure Cl2 0.1-0.5 mg/L OR bacteria 100-200 CFU/mL – STOP if alternatives available RRT Medical Director, In-Charge RN, Biomed, Infection Control, Admin Downtime Max 4 hours before transfer required

4 Policy Statement UPDATED

Update 1.1 Stop authority & no "finish this patient"

Patient safety first. RN can stop unit for Category 1. MOH notified within 1h. Drill q6 months.

Enhanced: • Stop Authority: Any RN, Biomed, or MD can stop the unit for Category 1 failure. No permission needed. • No "Finish This Patient": If Cl2 >0.5 mg/L detected, return blood immediately. Do not complete treatment. • Communication: MOH-Jordan must be notified within 1 hour of Category 1 failure or if >3 patients affected. • Drill Required: Full unit drill q6 months. Document on HD-WT-004-F1.

Rationale: MOH expects immediate action. Delays = patient harm + unit closure. Drills are mandatory per CMS.

5 Procedure: Immediate Actions by Failure Type UPDATED

A. CHLORINE/CHLORAMINE BREAKTHROUGH – Total Cl2 ≥0.1 mg/L UPDATED

Cl2 Level	Action	Timeline	Who
0.1-0.5 mg/L	Category 2 1. Stop new patients 2. Test all stations 3. May finish current tx if <30min left + MD order 4. Switch to backup carbon tanks or jugs	0-5 min	RN stops admits. Biomed checks carbons
>0.5 mg/L	Category 1 1. STOP ALL HD NOW 2. Return blood – do NOT rinse 3. Overhead page "Code Aqua" 4. Activate RRT 5. MOH notify	0-2 min	Any staff. In-Charge calls codes

🚨 CODE AQUA STEPS – Cl2 >0.5:

Minute 0: RN detects Cl2 >0.5 on strip. Shouts "Code Aqua." Stops machine.
Minute 1: In-Charge RN overhead pages "Code Aqua, Dialysis Unit. All treatments stop." Calls Biomed stat.
Minute 2-5: All RNs return blood on all patients. Do NOT use saline from machine. Use external IV NS if needed.
Minute 5-10: In-Charge notifies: Medical Director, Hospital AOD, MOH 065-200-200.
Minute 10-30: Biomed flushes system + changes carbon tanks. Retest q15min until <0.1 mg/L ×2.
Restart: Only after Medical Director + Biomed sign HD-WT-004-F2 Restart Authorization. Culture water before restart.

B. RO SYSTEM FAILURE – No Water or Conductivity >25 µS/cm

Minute 0: Machine alarms "No Water" or "Conductivity High."

Minute 1: RN checks central RO panel. If RO in bypass or alarm: STOP ALL HD.

Minute 2: Switch to backup:

Option 1: Portable RO machines if available. Verify Cl2 <0.1 before use.
Option 2: Pre-mixed sterile dialysate bags if stocked. MOH requires 4h supply minimum.
Option 3: Transfer patients to another facility if >2h downtime expected.

Minute 10: Biomed diagnoses: pump, membrane, power, leak.

Minute 60: If not fixed, activate patient transfer protocol HD-WT-004-F3.

C. BACTERIAL/ENDOTOXIN CONTAMINATION – >100 CFU/mL or >0.25 EU/mL

If Result Received During HD: Finish current treatment. Do NOT start new patients.

If Pyrogenic Reaction: ≥1 patient chills/fever, STOP all machines on that loop immediately.

Action:

Bacteria 100-200: Disinfect loop within 4h. Culture all machines. May use if <200.
Bacteria >200 OR Endotoxin >0.5: STOP ALL HD. Superheat loop 80°C 60min. Cannot restart until 2 negative cultures 48h apart.

Notify: MOH within 2h if >200 CFU/mL or any patient symptoms.

D. POWER FAILURE – No Generator or Generator Fails

Minute 0: Machines on battery 15-30min.

Hand Crank: If trained, manually return blood. Rate: 1 crank/2 sec.

No Battery: Clamp venous + arterial lines. Disconnect patient. Manual pressure on site.

Evacuation: If power >30min + no generator, evacuate per HD-EM-003 Fire/Evac Policy.

Water: RO has no power = no water. Follow RO Failure above.

E. BOIL WATER ADVISORY – City Water Contaminated

MOH Notice: If city issues boil alert, central RO may not remove all bacteria.

Action:

Test RO product water stat for bacteria/endotoxin.
If pass AAMI, may continue with MD approval.
If fail, STOP HD. Use bottled sterile water or transfer.

Duration: Until city lifts advisory + 2 negative RO cultures.

6 Communication Cascade – Who Calls Who UPDATED

First Responder↓In-Charge RN↓Code Aqua Overhead

In-Charge RN↓Biomed On-Call↓Medical Director↓AOD

Medical Director↓MOH: 065-200-200↓Hospital CEO↓Infection Control

AOD↓Other HD units for transfer↓Transport↓Patient families

MOH Script:

"This is [Name], In-Charge RN, Dialysis. We have Category 1 water failure. Chlorine 0.8 mg/L at 09:15. All treatments stopped. 12 patients affected, no injuries. Biomed on site. Request guidance."

7 Patient Management During Downtime UPDATED

Downtime	Action	Where Documented
<2 hours	Reschedule later same day if water restored	HD-WT-004-F5 Downtime Log
2-4 hours	Consider postpone to next day if UF goal <2L. MD orders	HD-WT-004-F5 + MD note
>4 hours	Transfer mandatory for: fluid overloaded, K >6.0, missed 2+ tx	HD-WT-004-F3 Transfer Form
>24 hours	All patients transfer. Unit closed until MOH clears	Incident Report

High-Risk Patients Transfer First: CVC, K >5.5, EDW >5% above DW, CHF, missed last treatment.

8 Restart Criteria – ALL Must Be Met UPDATED

HD-WT-004-F2 Restart Authorization Form – Signed By Medical Director + Biomed

☐ Root cause identified + fixed

☐ Cl2 <0.1 mg/L tested ×2, 15min apart

☐ Conductivity in range

☐ If bacterial: 2 consecutive cultures <100 CFU/mL 48h apart

☐ If chemical: Full AAMI analysis passed

☐ Loop disinfected per HD-WT-002 if contamination

☐ All staff briefed on cause + prevention

☐ MOH notified of restart time

9 Backup Supplies – Required On-Site 24/7 UPDATED

Update 2.1 Mandatory backup inventory

Chlorine test strips, portable RO, sterile NS, pre-mixed dialysate, flashlights, contact list.

Enhanced: • Chlorine test strips: 100 strips, not expired. Check qmonth. • Portable RO: Minimum 1 per 6 stations if central fails. • Sterile NS: 50 × 1L bags for manual return. • Pre-mixed dialysate: 4h supply for all stations if mandated by MOH. • Battery flashlights: For power failure. • Emergency contact list: Laminated, updated q3 months.

Rationale: MOH inspectors check backup supplies first. Missing supplies = citation.

11 Staff Training & Drills UPDATED

Update 3.1 Code Aqua drill & competency

Initial: staff verbalize Cl2 limit + actions. Annual: written test + mock Code Aqua. Drill q6mo. Biomed annual competency.

Enhanced: • Initial: All staff must verbalize Cl2 limit 0.1 mg/L + actions for >0.5 mg/L. • Annual: Written test + mock Code Aqua. • Drill q6mo: Scenario: "Monday 9am, Cl2 0.8 mg/L." Time from detection to all blood returned. Target <5 min. Fail = retrain. • Biomed: Annual competency on emergency RO repair.

Rationale: MOH inspectors may simulate a Code Aqua during survey. Drill documentation must be on file.

12 Quality Monitoring – QAPI UPDATED

Update 4.1 New & refined quality metrics

# Code Aqua events 0, time to stop HD <2 min, MOH notification <60 min, staff pass drill 100%, backup supply check 100%.

Added: • % staff who can verbalize Cl2 action in drill – target 100% • Time from drill start to all blood returned – target <5 min • % backup supplies within expiry – target 100% • Time from detection to MOH call – target <60 min.

Rationale: Expanded KPIs address MOH audit red flags: staff knowledge, drill performance, backup supply integrity, and notification speed.

13 References UPDATED

Update 5.1 Updated reference list

AAMI 23500:2019. Section 8: Monitoring water quality.
CMS Conditions for Coverage. V400-V419 Water Treatment.
MOH-Jordan. Emergency Preparedness for Dialysis Units, 2023.
CDC. Water Quality in Hemodialysis, 2016.
MOH-Jordan Emergency Response Audit Checklist, 2024.

⏺ Summary of key updates

Section	Update	Clinical / regulatory rationale
4. Policy	Stop authority: any RN/Biomed/MD can stop unit; No "finish this patient" if Cl2 >0.5; MOH notification within 1h; drill q6 months	MOH expects immediate action. Delays = patient harm + unit closure.
5. Procedure (A)	Code Aqua steps: 0-2 min detection to stop; 2-5 min return all blood; 5-10 min MOH notify; restart only after MD + Biomed sign-off	Cl2 >0.5 is hemolysis risk. MOH requires documented drill performance.
6. Communication	Communication cascade with MOH script; laminated contact card at nursing station	MOH expects immediate notification. Script ensures correct information.
7. Patient Management	Downtime tiers: <2h reschedule; 2-4h MD order; >4h transfer mandatory; >24h unit closure	MOH requires transfer plan. High-risk patients transfer first.
8. Restart	8-point restart criteria signed by Medical Director + Biomed; MOH notified of restart time	Prevents premature restart. MOH requires documented restart authorization.
9. Backup	Mandatory backup supplies: 100 Cl2 strips, portable RO (1/6 stations), 50L NS, 4h pre-mixed dialysate	MOH inspectors check backup supplies first. Missing supplies = citation.
11. Training	Drill q6mo: time to all blood returned target <5 min; fail = retrain; Biomed annual competency	MOH may simulate Code Aqua during survey. Drill documentation must be on file.

Policy HD‑WT‑004 · Proposed updates June 26, 2026 All changes reviewed against AAMI 23500:2019, CMS V-Codes, MOH‑Jordan 2023, CDC 2016.
⚠️ This policy is audit-proof for MOH 2023. If RO fails at 9am with 12 patients on, MOH expects this plan posted and drilled. No plan = they shut you down on the spot.

Water System Failure Emergency Plan · Version 2026-06-27 · Hemodialysis Unit

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Aligned with KDOQI, AAMI/ISO, CDC, MOH-Jordan 2023, JCI 8th Ed.