Lesson 1Criteria and red flags for urgent escalation or hospital readmission (worsening dyspnea, hypotension, rising creatinine, severe hyperkalemia)Explains clinic cut points and changing signs that need quick step-up or hospital return. Stresses pattern spot for worsening, structured 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, sugar, and kidney experts. Stresses send criteria, urgent levels, shared-care ways, and talk strategies to avoid double work 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)Gives a built follow-up time table after ED leave, including clinic visits, labs, and scans at 1-2 weeks, 2-4 weeks, and 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-led dose build clinics. Focuses on data flows, safety checks, and how far ways back timely med change and early spot of drop.
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 work with RAAS block, potassium with MRAs, and sugar with sugar plan changes, stressing time, cut points, 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 a step frame for changing treatment when answer is not enough, including dose build, switch drug types, and add second-line 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 careGives note shapes and words for short notes, including risk talk, follow-up plans, and safety nets. Fits guides for patients with small reach, low read, or shaky home 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 middle-term check aims after leave, focusing on life signs, weight, symptoms, stand-up pressure, and key lab marks to spot fluid build, 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 symptoms, pressure, and sugar measures. Makes clear cut points for win, part answer, and fail, 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
