Lesson 1Criteria and red flags for urgent escalation or hospital readmission (worsening shortness of breath, low blood pressure, rising creatinine, severe high potassium)This lesson explains clinical limits and changing signs needing urgent action or readmission. It stresses spotting patterns of decline, 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 nephrologyThis lesson outlines when and how to involve heart specialists, hormone experts, and kidney doctors. 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 emergency discharge, including clinic visits, labs, and scans at 1-2 weeks, 2-4 weeks, and three months, with flexibility by 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 lesson covers practical use of home devices, telehealth visits, and nurse-run dose increase clinics. It focuses on data flows, safety checks, and how distant methods aid timely medicine 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, including kidney function with RAAS blockers, potassium with mineralocorticoid antagonists, and blood 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 lesson describes a step-by-step frame for changing treatment when response is poor, including dose increases, switching drug types, and adding backup drugs, while balancing safety, other conditions, 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 lesson provides templates and wording for short records, including risk talk, follow-up plans, and safety nets. It tailors 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 peptidesThis lesson sets short- and medium-term monitoring aims after discharge, focusing on vital signs, weight, symptoms, standing blood pressure, and key lab markers to spot fluid buildup, kidney harm, sugar imbalance, and early treatment side effects.
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, and 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
