Lesson 1Criteria and red flags for urgent escalation or hospital readmission (worsening dyspnea, hypotension, rising creatinine, severe hyperkalemia)Explains clinic limits and changing signs that need quick up or hospital return. Stresses pattern spot for worsening, steady sort 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 bring in heart doc, sugar doc, and kidney doc. Stresses send rules, quick levels, shared-care ways, and talk strategies to avoid double and holes 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)Gives steady follow time table after ER out, including clinic visits, labs, scans at 1-2 weeks, 2-4 weeks, three months, with bend 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 real use of home check tools, far visits, and nurse-lead up-dose clinics. Focus on data flows, safety checks, and how far ways help timely med fix and early spot of down.
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 times for drug-bad effects, including kidney with blood vessel block, potassium with MRAs, and sugar with sugar plan changes, stressing time, limits, and fix ways.
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 step frame for fix treatment when answer not enough, including up-dose, switch drug types, add second-line, while balance safety, mixed sickness, 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 careGives templates and words for short notes, including risk talk, follow plans, and safety net. Fits guides for patients with small reach, low read, or bad house to cut avoid 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 middle-term check aims after out, focusing on life signs, weight, signs, stand-up pressure, and key lab marks to spot swelling, kidney hurt, body unbalance, 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 controlDefines how to judge treatment answer using signs, pressure, and sugar measures. Makes clear limits for win, part answer, and fail, and links each to special follow and fix 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
