Although we don't have a dialysis unit at the community hospital where I work, I'm often assigned to perform hemodialysis for patients with acute or chronic renal failure. Several days a week, only one nurse is assigned to perform dialysis, which sometimes means caring for two patients at once. I should mention that we dialyze patients in an otherwise-vacant unit in a relatively isolated part of the facility, so backup isn't nearby in an emergency. We do have a call light that we can use to summon help from another unit across the hospital.

I've been refusing to dialyze two patients when I'm alone because I feel it's unsafe under these circumstances. My manager says one nurse is enough to care for two stable patients in chronic renal failure. What do you say?-N.L., IDAHO

The main issue here is the patients' access to emergency care. Rather than a call light, a code phone should be available for summoning assistance. You and any other nurse performing dialysis should also have training in basic life support and, ideally, advanced cardiac life support.

Clearly, however, caring for even one unstable patient in acute renal failure is a far cry from caring for two stable patients with chronic conditions. Your facility should have a policy and procedure addressing appropriate staffing levels based on patient-acuity levels. If you believe staffing levels are inappropriate, find out what the norms are in similar facilities in your area. Also find out if any legislation on staffing ratios is pending in your state and check with the American Nephrology Nurses' Association (http://anna.inurse.com) for practice guidelines related to hemodialysis. If necessary, document this information and follow up with your manager and others in the chain of command, including the risk manager.