Lesson 1Criteria and red flags for urgent escalation or hospital readmission (worsening dyspnea, hypotension, rising creatinine, severe hyperkalemia)This explains health limits and changes needing quick step-up or hospital return. It stresses spotting patterns for worsening, set sorting questions, and clear action paths for patients and doctors in local settings.
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 bring in heart, hormone, and kidney specialists. It stresses referral rules, urgency, shared-care ways, and talk strategies to avoid repeats and gaps in follow-up in Gambian systems.
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 set follow-up time table after emergency discharge, including clinic visits, labs, and scans at 1-2 weeks, 2-4 weeks, and three months, with bend for risk and treatment strength.
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 real use of home check devices, phone visits, and nurse-led dose increase clinics. It focuses on data flows, safety checks, and how far-off ways help timely medicine changes and early spotting of worsening.
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, including kidney function with RAAS blocks, potassium with MRAs, and sugar with diabetes plan 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 changing treatment when reply is not enough, including dose ups, switching drug types, and adding backup drugs, while 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 templates and wording for short records, including risk talk, follow-up plans, and safety nets. It fits advice for patients with little access, low reading, or shaky homes to cut avoidable harm in Gambia.
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 after leaving hospital, focusing on vital signs, weight, symptoms, standing blood pressure, and key blood markers to spot fluid buildup, kidney hurt, body imbalance, and early treatment poison.
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, blood pressure, and sugar measures. It clears limits for success, part reply, and failure, and links each to set 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
