Four Items, One Morning, Caseload of 68
You carry a caseload of 68 members. At 9:00 on Monday morning you have four open items: (a) a voicemail left at 8:40 by a man discharged Friday after coronary artery bypass grafting, saying his "chest feels tight" and that he is out of pain medication; (b) a new emergency department referral for a 24-year-old woman with uncontrolled asthma who has no rescue inhaler and no prescription; (c) a payer fax requesting a care plan update on a stable nursing home resident, due by 5:00 p.m.; (d) a patient you have called twice over two weeks about a dialysis schedule change, who has not returned your calls.
1. Rank the four items and justify the order.
Read the worked answer
Rank by time-to-harm and actionability, not by arrival order, seniority, or how the request was routed to you.
1. (a) Post-CABG chest tightness. Within 72 hours of CABG, chest tightness could be graft ischemia or a pericardial process; it is a potential emergency and the only item on this list where the next hour changes the outcome. Call back immediately - do not leave a voicemail. If you cannot reach him, escalate to the emergency contact and consider a welfare check.
2. (b) Asthma with no rescue inhaler. High risk, fully actionable, and safely handled the same day: a call, a prescription request to the ED or PCP, and same-day pharmacy pickup. It is urgent but not measured in minutes.
3. (d) Dialysis non-response. Missing dialysis is life-threatening, but a two-week silence is more likely a wrong number or a disengaged patient than an acute event. Start with a records check and a call to the dialysis unit to confirm he is actually still attending - that answer decides whether this jumps to #2.
4. (c) The payer fax. Compliance and revenue matter, but it is administrative, it is about a stable member, and 5:00 p.m. is an internal deadline, not a clinical one.
Reasoning: triage on clinical consequence per unit of delay, then on whether I can actually change the outcome.
2. How do you handle the payer fax, and what may you delegate?
Read the worked answer
Delegate the task, not the accountability.
- The update itself - pulling existing assessment data and completing a templated care plan for a stable resident - is appropriate to delegate to an assistant or LPN per scope of practice and organizational policy, with a clear standard for what must be included.
- What stays with me: any clinical judgment in the document, any statement that certifies a level of care or ongoing need, and the final review before it is returned. Signing off on a care plan I have not read makes me the author of content I did not verify.
- What I do not do: let the fax displace item (a). Send a brief holding response if the deadline is genuinely hard, and complete it after the urgent calls.
- Use the opportunity: a "stable" designation is an assumption until confirmed. Note the date of the last assessment and verify that nothing has changed before attesting to it.
Reasoning: delegation is a scoping decision, not a time-management trick. Efficiency gained by delegating a judgment I am accountable for is borrowed, not earned.
3. The post-CABG patient refuses to call 911. Now what?
Read the worked answer
Stay on the line and work the refusal rather than accepting it.
- Get the clinical picture in the moment: where exactly is the tightness, does it radiate, shortness of breath, sweating, dizziness, and how long has it lasted? Rapid change in the answers changes the urgency.
- Make the recommendation specific and personal: "Chest tightness three days after bypass surgery is something we treat as a possible heart problem until we prove otherwise. That is why I want an ambulance, not a drive."
- Ask what the objection is. Cost, transport, fear of another admission, or a pet at home are all solvable; "no" usually has a reason attached.
- Bring in help he trusts - the spouse, adult child, or cardiology on-call - with his permission.
- If he still refuses: I can call 911 to his address; EMS response does not obligate him to accept transport, and the paramedics can assess him in the home. Offer that as the smaller step.
- Document: symptoms reported, the recommendation made, his stated reason for refusal, his apparent capacity to refuse, who was notified, and a firm call-back time.
Reasoning: an informed refusal by an adult with capacity is honored, but the obligation to try is not discharged by the first "no" - and documenting it protects both him and the record.