Lesson 1Criteria and red flags for urgent escalation or hospital readmission (worsening breathlessness, hypotension, rising creatinine, severe hyperkalemia)Explains clinical limits and changing signs needing urgent step-up or readmission. Stresses spotting patterns for worsening, structured sorting questions, and clear action paths 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 nephrologyOutlines when and how to involve heart, hormone, and kidney specialists. Stresses referral criteria, urgency, shared-care ways, 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)Provides a structured follow-up schedule after ED discharge, including clinic visits, labs, and scans at 1-2 weeks, 2-4 weeks, and three months, with adjustments based on 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 clinicsCovers practical use of home check devices, telehealth visits, and nurse-led dose increase clinics. Focuses on data flows, safety checks, and how distant ways aid timely medicine 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)Details check schedules for drug side effects, including kidney function with RAAS blockers, potassium with MRAs, and blood sugar with diabetes plan changes, stressing timing, 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 agentsDescribes a step-by-step frame for tweaking treatment on poor response, including dose increases, changing drug types, and adding backup drugs, while balancing safety, other illnesses, 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 careProvides templates and wording for short records, including risk talk, follow-up plans, and safety nets. Adjusts advice for patients with poor access, low reading, or unstable 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 peptidesDefines short- and medium-term check targets after discharge, focusing on vital signs, weight, symptoms, posture blood pressure, and key lab markers to spot fluid buildup, kidney harm, sugar imbalance, and early treatment toxicity.
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 controlDefines judging treatment response using symptoms, blood pressure, and sugar measures. Clarifies limits for success, partial response, and failure, and links each to specific 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
