Lesson 1Criteria and red flags for urgent escalation or hospital readmission (worsening shortness of breath, low blood pressure, rising creatinine, severe high potassium)Explains clinical thresholds and dynamic changes that require urgent escalation or readmission. Emphasises pattern recognition for decompensation, structured triage questions, and clear action pathways for patients and clinicians.
Worsening shortness of breath and new low oxygenLow blood pressure, fainting, and poor perfusionRising creatinine and reduced urine patternsSevere high potassium and ECG changesRapid weight gain and swelling progressionDesigning clear escalation algorithmsLesson 2Coordination with specialty care: when to refer to cardiology, endocrinology, and nephrologyOutlines when and how to involve cardiology, endocrinology, and nephrology. Emphasises criteria for referral, urgency levels, shared-care models, and communication strategies to avoid duplication 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)Provides a structured follow-up timetable after ED discharge, including clinic visits, labs, and imaging at 1–2 weeks, 2–4 weeks, and three months, with flexibility based on risk and treatment intensity.
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 clinicsCovers practical use of home monitoring devices, telehealth visits, and nurse-led titration clinics. Focuses on data workflows, safety checks, and how remote models support timely medication adjustment and early detection of deterioration.
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 (kidney function after RAAS inhibitors, glucose when changing diabetes meds, potassium with MRAs)Details monitoring schedules for drug-specific adverse effects, including kidney function with RAAS blockade, potassium with MRAs, and glucose with diabetes regimen changes, emphasising timing, thresholds, and mitigation strategies.
Renal labs after RAAS inhibitor changesPotassium monitoring with MRAs and diureticsGlucose checks after diabetes med changesRecognising early signs of drug toxicityAdjusting doses versus stopping therapyPatient counselling on warning symptomsLesson 6Stepwise therapy adjustments if inadequate response: uptitration, switching classes, adding second-line agentsDescribes a stepwise framework for adjusting therapy when response is inadequate, including uptitration, switching drug classes, and adding second-line agents, while balancing safety, comorbidities, and patient preferences.
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 careProvides templates and phrasing for concise documentation, including risk communication, follow-up plans, and safety-netting. Tailors instructions for patients with limited access, low literacy, or unstable housing to reduce preventable harm.
Key elements of follow-up documentationStandardised 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, standing BP, serum creatinine, electrolytes, HbA1c, and natriuretic peptidesDefines short- and medium-term monitoring targets after discharge, focusing on vital signs, weight, symptoms, standing blood pressure, and key laboratory markers to detect congestion, kidney injury, metabolic imbalance, and early treatment toxicity.
Prioritising vital signs and symptom reviewDaily weight and fluid status trackingStanding 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 controlDefines how to judge treatment response using symptoms, blood pressure, and glycemic metrics. Clarifies thresholds for success, partial response, and failure, and links each category to specific follow-up and adjustment 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
