Lesson 1Criteria and red flags for urgent escalation or hospital readmission (worsening shortness of breath, hypotension, rising creatinine, severe hyperkalaemia)This lesson explains clinical limits and changes needing urgent action or readmission. It stresses spotting worsening patterns, structured sorting questions, and clear action paths for patients and doctors.
Worsening shortness of breath and new low oxygenHypotension, fainting, and poor perfusionRising creatinine and low urine patternsSevere hyperkalaemia and ECG changesRapid weight gain and oedema progressionDesigning clear escalation algorithmsLesson 2Coordination with specialty care: when to refer to cardiology, endocrinology, and nephrologyThis lesson outlines when and how to get cardiology, endocrinology, and nephrology involved. It stresses referral criteria, urgency, shared-care setups, and talk strategies to prevent overlaps and misses 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 ED discharge, with clinic visits, labs, and scans at 1–2 weeks, 2–4 weeks, and three months, adjustable by risk and treatment level.
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 using home devices, telehealth visits, and nurse-led dose clinics. It focuses on data flows, safety checks, and how remote methods aid timely drug tweaks and early decline detection.
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 schedules for drug side effects, like kidney function with RAAS blockers, potassium with MRAs, and blood sugar with diabetes changes, stressing timing, limits, and fix 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 agentsThis lesson describes a step-by-step frame for tweaking therapy on poor response, including dose increases, class switches, and adding backup drugs, while balancing safety, other conditions, 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 careThis lesson provides templates and wording for clear 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 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, orthostatic BP, serum creatinine, electrolytes, HbA1c, and natriuretic peptidesThis lesson defines short- and medium-term monitoring aims post-discharge, focusing on vital signs, weight, symptoms, standing blood pressure, and key labs to spot congestion, kidney harm, metabolic issues, and early drug toxicity.
Prioritising 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 blood sugar measures. It clarifies limits for success, partial response, and failure, linking 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
