Lesson 1Criteria and red flags for urgent escalation or hospital readmission (worsening shortness of breath, low blood pressure, rising creatinine, severe high potassium)This explains health limits and changes needing quick action or return hospital stay. It stresses spotting worsening patterns, sorted questions, and clear steps for patients and doctors.
Worsening dyspnea and new hypoxiaHypotension, syncope, and poor perfusionRising creatinine and oliguria patternsSevere hyperkalemia and ECG changesRapid weight gain and edema progressionDesigning clear escalation algorithmsLesson 2Coordination with specialty care: when to refer to cardiology, endocrinology, and nephrologyThis outlines when and how to get heart, hormone, and kidney specialists involved. It stresses referral rules, urgency, shared care types, and talk ways to avoid repeats and misses in follow-up.
Indications for cardiology referralWhen to involve endocrinology teamsCriteria for nephrology consultationUrgent versus routine referral pathwaysShared-care and co-management modelsEffective interspecialty communicationLesson 3Initial follow-up schedule after ED discharge: timeline for clinic visits, labs, and imaging (1–2 weeks, 2–4 weeks, 3 months)This gives a planned follow-up calendar after emergency discharge, with clinic visits, labs, and scans at 1-2 weeks, 2-4 weeks, and three months, flexible by risk and treatment level.
Risk stratification to set visit timingVisit goals at 1–2 weeks post dischargeVisit goals at 2–4 weeks post dischargeThree-month reassessment prioritiesCoordinating labs and imaging windowsAligning follow-up with patient logisticsLesson 4Using remote monitoring and telehealth: home BP, weight logs, phone follow-up, and role of nurse-led titration clinicsThis covers using home devices, online visits, and nurse-run dose increase clinics. It focuses on data flows, safety reviews, and how distant ways aid timely drug tweaks and early spotting of decline.
Home blood pressure and heart rate logsDaily weight diaries and symptom trackersStructured phone and video follow-upNurse-led titration clinic protocolsAlert thresholds and response workflowsPatient education for remote tools useLesson 5Monitoring plan for drug-specific adverse effects (renal function after RAAS inhibitors, glucose when changing diabetes meds, potassium with MRAs)This details check schedules for drug side effects, like kidney function with RAAS blockers, potassium with MRAs, and blood sugar with diabetes changes, stressing times, limits, and fix strategies.
Renal labs after RAAS inhibitor changesPotassium monitoring with MRAs and diureticsGlucose checks after diabetes med changesRecognizing early signs of drug toxicityAdjusting doses versus stopping therapyPatient counseling on warning symptomsLesson 6Stepwise therapy adjustments if inadequate response: uptitration, switching classes, adding second-line agentsThis describes a step framework for tweaking treatment on poor response, including dose ups, class switches, and adding backup drugs, balancing safety, other illnesses, and patient likes.
Confirming adherence and measurement accuracySafe uptitration schedules and limitsWhen to switch within a drug classAdding second-line or adjunctive agentsMonitoring closely after each adjustmentDocumenting rationale for therapy changesLesson 7Documentation templates and safety-netting instructions for patients with limited access to careThis provides note patterns and wording for short records, including risk talks, follow-up plans, and safety nets. It fits advice for those with poor access, low reading, or shaky homes to cut avoidable harm.
Key elements of follow-up documentationStandardized discharge and clinic templatesPlain-language safety-netting phrasesAdapting plans for limited access to careUse of teach-back to confirm understandingRecording shared decision-making detailsLesson 8Short-term and medium-term monitoring parameters: vitals, weight, symptoms, orthostatic BP, serum creatinine, electrolytes, HbA1c, and natriuretic peptidesThis sets short- and medium-term check targets post-discharge, focusing on vital signs, weight, symptoms, standing blood pressure, and key labs to spot fluid buildup, kidney harm, sugar imbalance, and early drug issues.
Prioritizing vital signs and symptom reviewDaily weight and fluid status trackingOrthostatic blood pressure technique and timingCreatinine and eGFR trends after dischargeElectrolytes, HbA1c, and natriuretic peptidesIntegrating findings into risk stratificationLesson 9How to interpret response: definitions for success, partial response, and failure for symptoms, BP, and glycemic controlThis defines judging treatment reply using symptoms, pressure, and sugar measures. It clears limits for success, part reply, and failure, linking each to set follow-up and tweak actions.
Baseline symptom and risk documentationTargets for symptom improvementBlood pressure control thresholdsGlycemic control and HbA1c goalsDefining success, partial response, failureLinking response category to next steps
