Lesson 1Criteria and red flags for urgent escalation or hospital readmission (worsening dyspnea, hypotension, rising creatinine, severe hyperkalemia)This lesson explains clinical limits and changes needing urgent action or readmission. It stresses spotting worsening patterns, organized triage questions, and clear action paths for patients and providers.
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 lesson outlines when and how to involve heart, hormone, and kidney specialists. It stresses referral criteria, urgency, shared care models, and talk strategies to avoid repeats and gaps 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 lesson gives a structured follow-up schedule after ED release, including 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 lesson covers using home devices, telehealth visits, and nurse-led dose clinics. It focuses on data flows, safety checks, and how distant methods aid timely drug changes and early decline spotting.
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 lesson 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 lesson describes a step framework for changing therapy on poor response, including dose increases, class switches, and adding backup drugs, balancing safety, other conditions, and patient choices.
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 lesson provides templates and wording for short records, including risk talks, follow-up plans, and safety nets. It tailors advice for patients with poor access, low reading, or unstable homes to prevent 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 lesson defines short- and medium-term check targets after release, focusing on vital signs, weight, symptoms, standing blood pressure, and key labs to spot swelling, 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 lesson defines judging treatment response using symptoms, blood pressure, and sugar measures. It clarifies limits for success, partial response, failure, and links each to specific follow-up and change 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
