Lesson 1Criteria and red flags for urgent escalation or hospital readmission (worsening dyspnea, hypotension, rising creatinine, severe hyperkalemia)Explains health limits and changes needing quick action or hospital return. Stresses spotting patterns of decline, triage questions, and clear steps for patients and staff in Zambian hospitals.
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 get heart, hormone, and kidney specialists involved. Stresses referral rules, urgency, shared care, and talk methods to avoid repeats and gaps in Zambian 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 planned follow-up calendar after emergency discharge, with clinic visits, labs, and scans at 1-2 weeks, 2-4 weeks, and three months, flexible by risk and treatment in Zambia.
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 using home devices, phone visits, and nurse dose clinics. Focuses on data handling, safety, and how distant ways aid timely changes and early spotting of problems in rural Zambia.
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, like kidney after RAAS drugs, sugar with diabetes changes, and potassium with MRAs, stressing times, limits, and fix strategies in Zambian care.
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-by-step treatment changes for poor response, including dose ups, class switches, and adding backups, balancing safety, other illnesses, and patient likes in Zambia.
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 record templates and wording for short notes, including risk talks, follow-up plans, and safety nets. Fits advice for patients with poor access, low reading, or unstable homes to cut avoidable harm in Zambia.
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 peptidesSets short- and medium-term check goals after leaving hospital, focusing on vital signs, weight, symptoms, standing pressure, and key blood tests to spot fluid issues, kidney harm, sugar imbalance, and early drug problems in Zambian follow-up.
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 reply using symptoms, pressure, and sugar measures. Clears limits for good, partial, and failed results, linking each to specific follow-up and change actions in Zambia.
Baseline symptom and risk documentationTargets for symptom improvementBlood pressure control thresholdsGlycemic control and HbA1c goalsDefining success, partial response, failureLinking response category to next steps
