9.5 Facility and Water System Start-Up, Daily Monitoring Logs, and End-of-Day Shutdown
Key Takeaways
- Start-up follows a fixed order: water pre-treatment and reverse osmosis first, then the distribution loop, then the machines, with total chlorine tested and documented as acceptable before the first patient is connected.
- A start-up problem such as a broken reverse osmosis membrane seal must be resolved before dialysis proceeds; continuing because pressures appear normal ignores the loss of the barrier that removes dissolved contaminants.
- Daily logs record incoming water pressures, softener and carbon status, reverse osmosis percent rejection and conductivity or resistivity, deionizer resistivity, total chlorine results, temperatures, and any corrective action; the log is the facility's primary regulatory evidence.
- Residual germicide testing after any chemical disinfection must be documented as negative before a machine or loop returns to patient service, and the test must be performed at the point of use rather than only at the source.
- Shutdown secures the facility: machines rinsed and disinfected on schedule, loop disinfection or recirculation started, chemicals stored and secured, emergency exits clear, and any deferred problem communicated in writing to the next shift.
9.5 Facility and Water System Start-Up, Daily Monitoring Logs, and End-of-Day Shutdown
Quick Summary: Start-up facility and shut down facility appear as activities 13 and 17 in the Role Responsibilities practice area. The advanced technician who opens the unit is the last barrier between a municipal water event overnight and twenty patients connected at 5:30 a.m.
Morning Start-Up, In Order
Start-up runs upstream to downstream. Nothing at the machine matters if the water feeding it is wrong.
1. Facility and safety. Unlock and light the unit. Confirm emergency exits are unobstructed, the emergency cart seal is intact and the cart is checked, fire extinguishers are in place with current inspection tags, eyewash stations flow, and the chemical storage area is secure and free of spills.
2. Incoming water and pre-treatment.
- Confirm the backflow preventer is intact and no cross-connection exists.
- Read incoming water pressure and temperature; blended water temperature affects reverse osmosis rejection.
- Check the multimedia filter pressure differential and confirm the overnight backwash completed.
- Check the softener: brine tank has adequate salt and is not bridged or crusted, regeneration completed on schedule, and product-water hardness tests within limits. An underfilled brine tank means an incomplete regeneration and elevated water hardness downstream, which fouls the reverse osmosis membrane.
- Check the carbon beds: worker and polisher tanks in service, adequate flow, and the sample ports accessible.
3. Total chlorine - the gate. Run the required 15 minutes of operating flow, then draw from the post-worker sample port and test total chlorine with an in-date reagent. The result must be < 0.10 mg/L and must be documented before the first patient treatment of the day begins. This is a hard stop, not a checklist item to complete later. Testing free chlorine alone is insufficient - chloramines are measured only in the total chlorine result.
4. Reverse osmosis and deionization.
- Start the RO and let it stabilize.
- Record feed, product, and reject pressures; percent rejection (target commonly at or above 90-95%); and product conductivity or resistivity.
- Inspect for leaks, broken seals, and abnormal noise. A broken RO membrane seal that is leaking is a stop condition. Normal pressures do not mean the membrane is intact - a bypassing seal lets feed water carrying dissolved solids, aluminum, and fluoride pass straight through. The correct action is to delay dialysis until the membrane is repaired, not to continue while pressures look acceptable and not to run on deionization bypass as a substitute barrier.
- Where a DI polisher is used, confirm resistivity ≥ 1 megohm-cm at 25 degrees C and that the audible alarm and automatic diversion are functional. An exhausted DI bed can dump previously bound ions - including aluminum - in a bolus.
- Confirm the post-DI ultrafilter or endotoxin filter is in service and within its change interval.
5. Distribution loop. Confirm the loop is recirculating at design velocity, that any overnight disinfection cycle completed, and - critically - that residual germicide testing is negative at the point of use for every affected outlet before any machine is connected. Testing only at the source misses a dead leg holding germicide.
6. Machines. Bring machines up, run the manufacturer's pressure holding and alarm tests, verify the machine has completed its rinse after overnight disinfection, and test for residual germicide at the machine where chemical disinfection was used. Verify conductivity and pH independently with a calibrated external meter on the required schedule. Confirm each machine clears bypass and holds temperature.
7. Station and supplies. Disinfected surfaces dry, supplies stocked, sharps containers below the fill line, waste receptacles in place, chairs functional with working brakes, and the walkway clear.
8. Documentation. Sign the log. An undocumented check is, for regulatory purposes, a check that did not occur.
The Daily Monitoring Log
| Log entry | What it proves |
|---|---|
| Incoming pressure and temperature | Adequate supply; RO performance context |
| Multimedia filter differential | Filter not blinded; backwash effective |
| Softener hardness result; salt level | Regeneration adequate; RO membrane protected |
| Total chlorine, pre-first-treatment and every 4 hours | Carbon beds protecting patients from chloramine |
| RO pressures, percent rejection, product conductivity | Membrane integrity and rejection performance |
| DI resistivity | Polisher not exhausted; no aluminum dump risk |
| Loop pressures and temperature | Circulation maintained; no stagnation |
| Residual germicide results | Disinfectant cleared before patient use |
| Water and dialysate culture and endotoxin results (per schedule) | AAMI/ISO microbial limits met |
| Corrective actions taken | The facility acted on out-of-range findings |
Logs are reviewed by surveyors, by the medical director, and by the quality assessment and performance improvement (QAPI) committee. Trends matter more than single points: a percent rejection drifting from 97% to 91% over six weeks is a membrane nearing replacement, and the technician who flags the trend prevents the failure.
Never backfill a log. A row completed from memory at the end of the day is a falsified record and, under NNCC policy, falsification of documentation is grounds for loss of certification.
Handling Abnormal Start-Up Findings
| Finding | Action |
|---|---|
| Total chlorine ≥ 0.10 mg/L post-worker | Test post-polisher immediately; if polisher is safe, continue with intensified surveillance and schedule tank replacement; if polisher also fails, no treatments begin |
| Broken or leaking RO membrane seal | Delay dialysis until repaired; do not substitute DI bypass |
| Softener hardness out of limits | Regenerate, retest, and protect the RO; report |
| DI resistivity below 1 megohm-cm | Take DI out of service; replace bed; retest |
| Positive residual germicide at any point of use | Rinse further and retest until negative; no patient connects until it is |
| Machine fails pressure or alarm test | Tag, remove from service, notify biomedical |
| Emergency exit blocked or extinguisher out of date | Correct immediately and report |
End-of-Day Shutdown
- Complete all treatments and confirm every patient has been assessed post-treatment and discharged safely.
- Disinfect machines per the schedule - heat, chemical, or citric - and record the cycle. Where chemical germicide is used, note that residual testing will be required before the next patient use.
- Disinfect and rinse bicarbonate jugs and lines; empty rather than top off.
- Perform loop disinfection or set recirculation per policy; a stagnant loop overnight is a biofilm incubator.
- Shut down or place in standby the RO per manufacturer instruction, and secure the pre-treatment equipment.
- Clean and disinfect station surfaces, chairs, machine exteriors, and shared equipment.
- Secure chemicals in the locked, ventilated, properly labeled storage area with Safety Data Sheets accessible; secure oxygen cylinders upright.
- Dispose of regulated medical waste and sharps containers that have reached the fill line; do not overfill.
- Clear the environment: no clutter in walkways, emergency exits unobstructed, spills cleaned, cords off the floor.
- Communicate in writing anything deferred - a tagged machine, a carbon tank due for change, a scale awaiting calibration, a pending culture result - so the opening technician does not rediscover it at 5:30 a.m.
- Secure the building per policy and complete the shutdown log.
The through-line for both start-up and shutdown is the same: the advanced technician is accountable not for a single patient's treatment but for the condition in which the whole facility opens and closes.
When starting up the water system in the morning, the technician notes that the reverse osmosis membrane seal is broken and leaking. Which action is appropriate?
At morning start-up, which requirement must be satisfied and documented before the first patient treatment of the day may begin?
A technician performing end-of-day shutdown discovers a dialysis machine that was tagged out of service earlier in the day and a carbon tank that is due for replacement tomorrow. What should be included in the shutdown process?