Sick vs not-sick before any chart. Eyes on the patient: posture, color, work of breathing, distress. The fellowship's "across-the-room assessment" — your gut activates the rest of the tree.
2 · ABCD
Airway — talking in full sentences? Breathing — rate, accessory muscles, diaphoresis. Circulation — color, cap refill, skin. Disability — LOC (level of consciousness), GCS (Glasgow Coma Scale), orientation. Any failed letter = stop, fix, call for help.
3 · Sort (ESI logic)
ESI 1 = don't triage, resuscitate. ESI 2 = high-risk situation or high-risk vitals (HR >100/<50 · RR >20/<10 · SpO2 <92% · SBP <90) — should not wait. ESI 3–5 = count resources.
4 · Bundle (beat the clock)
Every emergency has a clock: ECG ≤10 min · door-to-balloon 90 · sepsis Hour-1 bundle · TNK window · MTP cooler. Recognize the pattern → run its time-critical bundle. The panic row jumps straight to each one.
5 · Escalate (SBAR, chain of command)
Bedside → Charge → Supervisor → House Supervisor → Director. Communicate in SBAR (Situation · Background · Assessment · Recommendation). Escalation is a duty, not an option — patient safety concerns, unclear orders, disagreement with plan, staffing.
6 · Document (or it didn't happen)
Real-time, objective, complete. "I can either do it or document it — do both." Extra care on high-risk dx: peds fever, chest pain, abd pain, AMS, worst-headache-of-life, fractures, wounds.
7 · Reassess & re-prioritize
Highest acuity first; new or worsening symptom jumps the queue. Delegate safely to the tech (UAP) (with fall precautions). Lather, rinse, repeat until handoff.
Orientation Tiers — TSAM
TSAM = Tiered Skills Acquisition Model. Source: official IFMC "TSAM Orientation Guide and Checklist" packet (Caitlyn Lucky, 3/17/2025). Each tier = objectives + preceptor sign-off (initials/date). Ratio note from packet: orientees may be capped at 1:4 or 1:5 for Tiers 1–3. Preceptor duties every tier: model best practice + intentional caring, narrate care, time management, debrief end of shift (what went well / growth areas), review skills checklist + orientation pathway in HealthStream.
Tier 1 · VS, Assessments, Doing & Documenting
Skills: Perform + document VS (compare to last shift), blood glucose checks. Knowledge/Skills: Accurate assessments documented in flowsheets — time goal: within first 5 hours of shift. Focus flowsheets: VS · Assessment · IV Assessment · Daily Care/Safety · MEWS/SIRS. Harm prevention: falls bundle, skin assessment/doc, seizure, aspiration, bleeding precautions. Rounding: hourly rounding + accurate white-board updates. Escalation: evaluate MEWS (Modified Early Warning Score) + SIRS screening — know how/when to escalate. Interpersonal: learn two things about each patient you can't find in the chart. Neuro: neuro assessment, NIH stroke scale, stroke protocol (Unit 25 only in packet — ED: stroke class applies). Resource time: assessments, flowsheet documentation, Epic setup.
Tier 2 · Medications, Orders & Specimens
Med safety: safely passes meds (5 rights: patient · drug · dose · route · time), documents + reassesses all patients — pain-med reassessments, BP before BP meds. Education: teach meds + document patient/family response (Teach-Back; Krames + Micromedex as resources). I&O: intake/output flowsheet incl. IV meds, continuous fluids, piggybacks. Device bundles: CAUTI (use bladder scanner) · CLABSI · blood + urine culture algorithms · Foley algorithm. Orders management: know when new orders land, acknowledge, find active orders, release signed & held orders. Resource time: IV pump, hanging IV fluids, piggyback.
Tier 3 · Admissions, Discharges, Transfers & Communication
ADT: completes admissions/discharges/transfers independently, documents in Navigators. Report: leads bedside shift report using ISHAPED (Introduce · Story · History · Assessment · Plan · Error-prevention · Dialogue; complete chart check in flowsheets) · trio-rounding with SBAR. Comms: carries the phone, manages calls. Labs: obtains specimens (SoftID), interprets results, correlates labs/diagnostics with patient condition. Prep: pre-op/procedure prep (Pre-Op checklist) · death checklist + post-mortem care process. Critical thinking: recognizes improving vs declining patient and escalates (concept map encouraged). Resource time (PD team sign-off): specimen collection, IV/phlebotomy, concept map, SBAR + bedside report practice.
Tier 4 · Complex Care Planning & High-Risk Procedures
Procedures: central line dressing changes, complex wounds/wound vac, chest tubes, NGT, PCA (patient-controlled analgesia), RACD, Foley/straight cath, blood administration, heparin drip, cardiac drips (unit-specific), CBI (continuous bladder irrigation), CIWA (alcohol-withdrawal scale)… Find your sources: locate Lippincott · locate Policies (Policy Scavenger Hunt in Canvas). Comms: X-tend page (urgent) · Epic Secure Chat (non-urgent) · know e-ICU and when to contact. Trends: assess trends in condition and respond. ⚑ Packet milestone: "If not already, move to care of FULL patient load." Resource time: teaching round with PD team, SBAR practice.
Tier 5 · Workload Management
The bar: entire assignment with minimal guidance — all assessments, documentation, PRNs, scheduled meds. Skills: organization + prioritization · navigate full-assignment complexity without preceptor direction. Interpersonal: model caring toward patients, families, colleagues. Exit task: collaborate with unit leadership/AC on your post-orientation schedule (Smart Square).
How this maps to YOUR ED fellowship
TSAM tier
Your timeline
ED overlay
1–2
Tier 1 shifts May 19 – Jun 4
Foundations · Device Day · Vascular Access · Charting 101 · ESI Triage classes + low-acuity preceptored patients
Full load; PIAT capstone Sep 2–3; Smart Square scheduling off orientation
⚠ Packet origin is MCCSU/TACS/Neuro mentorship (some items inpatient-flavored: ISHAPED, trio-rounding, Unit 25). Confirm with your ED preceptor which line-items the ED tracks verbatim vs adapts.
Procedures — anticipate · prep · assist
Quick-pull index of every procedure the orientation material expects you to prep for or assist. Spine: Device Day stations, TSAM (Tiered Skills Acquisition Model) Tier-4 list, fellowship classes, PWA protocols. Supplies marked (std) are standard evidence-based lists (ENA/BCEN-style) where Inova material doesn't itemize — verify against your unit stock.
Meds & Drips — the pharm index
Every medication taught across the fellowship (RSI handout, High-Risk Meds class, sepsis/stroke/cardiac/OB/BH decks, protocol data). Doses are orientation teaching values — pump library + PolicyStat + provider order always win. Universal rules: 2-RN verification for all high-risk meds/drips · IHS Patient ID policy before anything · know your antidotes · document response after every dose.
Tools & Notes
GCS — Glasgow Coma Scale
GCS 15 — mild / baseline
≤8 = consider airway protection · 9–12 moderate · 13–15 mild. Use peds GCS under age 2.
Total dose = dose/kg × weight(kg). Volume = dose ÷ concentration. Drip mL/hr = (mcg/kg/min × kg × 60) ÷ conc(mcg/mL). Always cross-check with the pump library + second RN — this tool checks math, not orders.
🩺 Diagnostics — real fixes only
📝 Memos — timestamped, editable, exportable
Notes live in this browser's storage (~5 MB ≈ thousands of notes; survives reloads & restarts, but NOT clearing browser data or switching devices). Routine: export weekly → drop the .md into your OneDrive/Google Drive "ED_Notes" folder → then Clear when it feels heavy. Each export is one clean timestamped file, so your Drive folder stays a tidy single archive.
Documentation templates — handoff-grade first notes
ED charting standard per your teaching: clear · concise · time-stamped — the next nurse takes over from this note alone. Tap one or MORE blocks (universal skeleton always included), then Build. Blanks = ___, fill at the bedside.
Timers
Timers beep + vibrate + (if you allow notifications) pop a system notification when done. They live while the page is open (a timer that silently died with a closed tab is worse than none — by design). The ⏱ chip in the header shows the soonest timer from anywhere.
Print / Share
Pick sections → Print / Save PDF uses your phone’s native dialog (Wi-Fi/USB printers + Save as PDF). Share / Email opens the share sheet → Gmail with the content in the body, ready to review and send. Pixel-perfect email: Save as PDF, then share the PDF.
Focused assessment builder
Pick the complaint → get the focused questions, the exam in order, and the red flags that change the day. Check items off as you go; copy or save the run when done. Built from your fellowship classes + ENO 3.0 assessment chapters.
Special situations — gap closers
Low-frequency, high-stakes events the core classes touch lightly. Inova-sourced where it exists; clearly-cited standard practice (outside sources) where it doesn't.
Supplemental — the complete study map
Where every deeper layer lives, mapped to this tree. ENO 3.0 = ENA Emergency Nursing Orientation Course Notebook (in 11_Curriculum_ENO_Elsevier).
ENO 3.0 chapters → tree sections
ENO 3.0 chapter
Tree home
Cardiovascular I & II (dysrhythmias, arrest, ACS, HF, aortic)
07 Cardiac · panic STEMI/Arrest · Syncope
Respiratory / airway
06 Respiratory · RSI
Neurologic
10 Neuro · Stroke
Shock · Fluid/Electrolytes & Vascular Access
Sepsis · MTP · 03 Vascular
Behavioral Health · Maltreatment/IPV · Forensics
12 BH · Wound abuse screen · Special situations
OB/GYN · Pediatric
13 OB · Peds threads · MORE complaints
Toxicology · Endocrine · Environmental
MORE complaints (Overdose · DKA) · Special situations
ED Nursing Curriculum 2024 (the course) → ASAP Exercise Booklet (hands-on) → tip sheets in 03_PROFESSIONAL/Epic_ED_Narrator_Guides (33 PDFs + 21 policies) → F1 inside Epic = Learning Home → TLC site for the newest sheets. The 📝 Documentation entry card condenses all of it.
Fellowship class files
12_Fellowship_Class_Content: every class folder (01–16) with handouts + _alt_versions drafts · 13_Orientation_Onboarding: schedules, TSAM packet, Teams PPTs · Mocks: STEMI/VF (07), NIHSS/TNK (10), Code Narrator adult+peds (14).
Order of draw + tube guide are CLSI-standard (outside source — verify against the lab's posted chart); Inova-specific rules below come from your tip sheets & policies.
Order of draw — top to bottom
#
Tube
Typical tests
Notes
1
🟡 Blood culture bottles
Cultures ×2 sets
ALWAYS first (sterility) · before antibiotics · fresh sticks per policy
2
🔵 Light blue (citrate)
PT/INR · PTT · fibrinogen
MUST fill completely — short fill = bad coags · discard tube first if off a line per policy
Blood-bank armband rules per policy — label at bedside, no exceptions
7
⚪ Gray (fluoride)
Lactate (site-dependent) · EtOH · glucose
LEGAL alcohol = law-enforcement kit + non-alcohol prep + chain of custody, NOT this tube
Inova specimen rules (from your docs)
• Scan patient + scan label with Rover/Beaker (SoftID) — bedside, every time (Mar 2025 tip sheet)
• Blood cultures ×2 BEFORE antibiotics, fresh sticks; peds culture quick-list updated Mar 2026
• Lab status board: Lab Overview tip sheet (May 2025) — view & manage collections from Epic
• Legal blood alcohol: IHS policy — law-enforcement kit, non-alcohol prep wipe, documented chain of custody, you may decline if it compromises care
• Unsuccessful IV attempts get documented too (Jul 2025 flowsheet)
• Hemolysis prevention: no prolonged tourniquet, no tiny-gauge hard draws, gentle inversion, no squeezing the IV line
Next-check auditor
Tell it what's running and when it started (or when you last checked) — it computes every due time per the schedule and counts down. Presets marked ⚠ aren't in your saved Inova docs: interval is editable, confirm on PolicyStat. Heparin has its own dedicated tool → 🩸 Heparin Auditor
🩸 Heparin Auditor
Teaching logic — verify on PolicyStat. Heparin nomograms, lab type (aPTT vs anti-Xa), target ranges, and recheck intervals are institution-specific. Set yours below once you've confirmed the Inova protocol; until then the defaults are flagged. This audits YOUR data and drafts the questions — the nomogram order set and the provider make the calls.
0.25 mg/kg MAX 25 mg · 2-RN · then q15 neuro checks
ED Map — IFMC Adult ED
⚠ No floor map in the library yet. The only maps on file are campus walking directions (Campus_Maps). Snap a photo of the unit map / zone board and drop it in Files_Main-base → Claude wires it in here. Until then:
Zone & bed placement logic (from policy data)
Zone assignments & bed placement, hallway/hall-bed protocol, boarding rules, and immediate-bedding criteria exist as protocols in your PWA (zone-assignments · hallway-protocol · boarding-rules · immediate-bedding). The placement algorithm mirrors triage: acuity → monitored vs non-monitored need → zone capability → hallway only per protocol.
Why the map matters to the theme
The universal algorithm runs on geography: where the Belmont lives, which bays take traumas, where the Omnicell / crash carts / difficult-airway cart sit, the walking flow triage → zone → CT → trauma bay. Once the real map is in, each entry point gets a "where" line.