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Canadian Journal of Emergency Medicine (20)
Prehospital and Disaster Medicine (1)
Canadian Association of Emergency Physicians (CAEP) (20)
World Association for Disaster and Emergency Medicine (1)
P077: Piloting imaging-focused knowledge dissemination tools in Alberta emergency departments
L. Krebs, N. Hill, C. Villa-Roel, S. Couperthwaite, M. Ospina, B. Holroyd, B. Rowe
Journal: Canadian Journal of Emergency Medicine / Volume 21 / Issue S1 / May 2019
Published online by Cambridge University Press: 02 May 2019, p. S91
Introduction: Variation in image ordering exists across Alberta emergency departments (EDs). Evidence-based, pocket-sized knowledge dissemination tools were developed for two conditions (acute asthma [AA] and benign headache [BHA]) for which imaging (chest x-ray [CXR] and computed tomography [CT], respectively) has limited utility. This study explored tool acceptability among ED patients and emergency physicians (EPs). Methods: Tool feedback was provided by EPs, via online survey, and adult patients with AA and BHA via in-person survey. EPs qualitative interviews further explored communication tools. Preliminary descriptive analyses of survey responses and content analysis of interview data were conducted. Results: Overall, 55 EPs (55/192; 29%) and 38 consecutive patients participated in the AA study; 73 EPs (73/192; 38%) and 160 patients participated in the BHA study. In both studies, approximately 50% of EPs felt comfortable using the tool; however, they suggested including radiation risk details and imaging indications and removing references to imaging variation and health system cost. In the BHA study, EPs opposed the four Choosing Wisely® campaign questions fearing they would increase imaging expectations. In both conditions, most patients ( >90%) understood the content and 68% felt the information applied to them. Less than half (AA:45%; BHA: 38%) agreed that they now knew more about when a patient should have imaging workup done. Following tool review, 71% of AA and 50% of BHA patients stated they would discuss their imaging needs with their ED care provider today or during a future presentation. Both patient groups suggested including: additional imaging details (i.e., indications, risk, clinical utility), removing imaging overuse references, and including instructions that encourage patients to ask their EP questions. EP interviews (n = 12) identified preferences for personalized and interactive tools. Tensions were perceived around ED time pressure as well as remuneration schemes that fail to prioritize patient conversation. Tool centralization, easy access, and connection with outpatient support were also key themes. Conclusion: Both patients and EPs provided valuable information on how to improve ED knowledge dissemination tools, using two chronic conditions to demonstrate how these changes would improve tool utility. Implementing these recommendations, and considering preferences of EPs and patients, may improve future tool uptake and impact.
P149: Benign headache management in Alberta emergency departments: a chart review study to explore gaps in practice
J. Gouda, N. Runham, L. Krebs, S. Couperthwaite, B. Rowe
Published online by Cambridge University Press: 02 May 2019, p. S118
Introduction: Variation in medication management and image ordering for HA presentation to emergency departments (ED) has been documented. This study examined benign HA (i.e., migraine, cluster, tension) management in order to identify the consistency and appropriateness of HA management in EDs in Alberta. Methods: Patients were identified by primary discharge diagnosis in the National Ambulatory Care Reporting System using ICD-10-CA codes for benign HA (G43, G44, R51). Patients presenting to study sites from January 1, 2017 to September 30, 2017 were eligible for inclusion, provided they were adults (≥18 years), were not transferred from another institution or directly admitted to a service, and had an active HA at presentation. One hundred eligible patients were randomly selected for chart review. Data were extracted on standardized forms. Preliminary data on 50 patients (n = 150) from three Edmonton study sites is presented. Results: Most patients arrived to the ED via personal transportation (93%) and were assigned a Canadian Triage and Acuity Scale (CTAS) score of 3 (71%). The majority of patients were female (75%); mean age was 45 years (standard deviation: 18). Triage pain score was not documented for 21%. When documented, pain scores were most frequently between 4 and 7 (49%). Nearly 10% of patients left without being seen. For those who were assessed, physicians most frequently used ketorolac and metoclopramide as first or second line treatments or as a combination treatment. Consults were infrequent (14%). Nearly half of the patients (47%). had computed tomography (CT) in the ED. Pain re-assessment was completed for 69% of patients. Most patients were discharged from the ED (88%) and given some form of discharge instruction (78%). The most common instructions were to return to ED as needed (45%) and follow-up with their primary care physician (28%). Across all patients, 13% returned to the ED with headache within 30 days. Conclusion: Physicians treat patients with benign headaches appropriately and hospitalization is infrequent; however, one in eight patients relapse. Missing pain scale documentation reveals a potential problem for ED clinicians in assessing management effectiveness and ensuring patients leave the ED following pain relief. Half of the patients received a CT scan, highlighting the urgent need for an intervention to address CT overuse for patients with benign HA within this geographic region.
P076: Do QR codes effectively engage patients in research while visiting the emergency department?
L. Krebs, C. Villa-Roel, D. Ushko, G. Sandhar, H. Ruske, S. Couperthwaite, B. Holroyd, M. Ospina, B. Rowe
Published online by Cambridge University Press: 02 May 2019, pp. S90-S91
Introduction: Efforts to engage patients in research when presenting to emergency departments (EDs) have explored the utility of online tools; for example, through QR-based applications. It is unclear whether these are effective strategies for engaging patients in research activities while saving costs of in-person surveys. This study evaluated whether patients would participate in QR codes or short URL-linked surveys available in EDs across Alberta. Methods: A patient waiting room poster was developed as part of a stepped-wedge randomized controlled trial. The waiting room poster was introduced in 15 urban and regional Alberta EDs with a median annual volume of approximately 60,000. A QR-code and short URL were placed on the poster inviting patients to participate in an online survey and evaluate the poster's usefulness and acceptability. Additionally, written discharge instructions, which were part of the intervention materials, were distributed with QR-code and short URL link to surveys for patients to share their ED care experience. Patients were not prompted by any staff or research personnel to encourage use of the QR codes or the short URLs; however, a survey was conducted with ED waiting room patients in 3 urban EDs to ascertain whether they had downloaded a QR reader on their devices and the frequency of use of these applications. Results: Given the stepped-wedge nature of the study, these materials were available for a total of approximately 123 months (3 sites for 13 months, 4 sites for 10 months, 4 sites for 7 months, and 4 sites for 4 months). Over the study period, 15 patients accessed and completed the online survey linked to the QR code or the short URL placed on the posters. No patients completed the online surveys linked to the QR code or the short URL placed on the discharge instructions. The in-person survey conducted within the ED waiting room identified that 34% of respondents had a QR code reader downloaded on their phone (108/316). Of those with a QR reader, 33% reported using the reader at least once within the last 6 months. Conclusion: In this study, few patients downloaded QR readers on their electronic devices while in the ED waiting room. Without prompting, this appears to be an ineffective strategy for engaging patients in emergency medicine research. Other engagement strategies optimizing human resource investment are urgently needed to effectively conduct research in EDs.
P075: Emergency physicians' self-reported management of benign headache in Alberta emergency departments
L. Krebs, C. Villa-Roel, S. Couperthwaite, M. Ospina, B. Holroyd, B. Rowe
Introduction: Benign headache (BHA) management varies across emergency departments (EDs). This study documented current BHA management by Alberta emergency physicians (EP) in order to develop a provincial intervention to improve standardized practice. Methods: A convenience sample of Alberta EPs completed an online survey exploring their ED BHA management practices. Results are expressed as proportions. Results: A total of 73 EPs (73/192; 38%) who were mostly male (63%) and practiced emergency medicine for at least 15 years (51%) responded. EPs reported routine ED orders for metoclopramide (97%), ketorolac (90%) and IV fluids (85%) for patients with BHA showing no signs of pathological headache. For moderate-severe BHA's that did not improve with routine treatment, preferences were: IV narcotic (58%), IV dexamethasone (44%), and IV/IM dihydroergotamine (27%). Typically, EPs reported not ordering investigations for moderate-severe BHA presentations (88%); however, for those not improving the most common investigation was computed tomography (CT; 47%). CT ordering was associated with the following clinical scenarios: 1) not responding to traditional therapy and consulted to specialist (64%); 2) not responding to traditional therapy and being admitted (64%); 3) first presentation and afebrile (19%); 4) severe pain (11%); and 5) responding to traditional therapy and febrile (11%). One-quarter of EPs (27%) believed their patients usually or frequently expected a CT. Most EPs (60%) reported being completely or mostly comfortable discussing CT risks. Only 44% reported always or usually discussing risks prior to ordering. EPs reported that they were most frequently prevented from discussing risks because the patient was critically ill (42%) or because they believed explaining risks would not alter patient expectations (21%). These concerns were mirrored in the barriers EPs anticipated to limiting imaging, specifically the fear of missing a severe condition (62%), and patient expectation/request for imaging (48%). Conclusion: Self-reported treatment preferences for uncomplicated BHAs appear to be relatively consistent. Chart reviews could help assessing the reliability of self-reported BHA management practices. Perceived patient expectation appears to be an important influence on EP imaging ordering. Studies examining the communication between EPs and their patients are needed to explore how these expectations and perceived expectations are negotiated in the ED.
P147: Your emergency department journey: piloting a patient poster explaining the emergency department care process
Introduction: Qualitative research with emergency department (ED) patients in Alberta has revealed that some patients have limited understanding of the ED care process and that this increases the anxiety, frustration and confusion experienced throughout their visit. The objective of this study was to design, implement, and test the usefulness of a poster explaining the ED care process. Methods: As part of a stepped-wedge ED intervention trial in Alberta, a 4′ x 3′ poster portraying the patient ED care process was developed and posted in 15 study site waiting rooms. Trained research assistants approached patients in 3 urban ED waiting areas and invited them to complete a short paper-based survey on the acceptability and usefulness of the poster. Results are reported as proportions. Results: A total of 316 patients agreed to participate in this study. Approximately half of the participants were male and 60% were between the ages of 17 and 49. The majority of participants identified themselves as white (72%) and nearly half (49%) were accompanied by someone. A third (37%) of patients had read the wall poster prior to being approached to complete the survey. Most patients (62%) who had not read it prior to being approached hadn't noticed the poster or couldn't see it because of its location. Once patients reviewed the poster, the vast majority (92%) reported completely or largely understanding the information and most (84%) found it at least moderately helpful in preparing them for their ED journey. Approximately 45% of respondents agreed that they learned something new about the ED care process by reading the poster and 20% wanted additional information added to the poster; largely, wait time estimates (53% of responses). Conclusion: Placing posters in the ED is one method for equipping patients for their ED care process; however, this study revealed the potential limited utility of this engagement method by the small number of patients who noticed the poster and read the information. Location and content (e.g., time estimates) were identified as key factors for implementation. Condition-specific guides may need to supplement general ED process guides to better prepare patients for their individual ED journey and to actively engage them in their ED care.
P148: Emergency physicians' perception on engaging patients in their emergency department care
L. Krebs, C. Villa-Roel, S. Couperthwaite, B. Holroyd, M. Ospina, B. Rowe
Published online by Cambridge University Press: 02 May 2019, pp. S117-S118
Introduction: Patient engagement in health decision-making is an important research area within emergency medicine. Studies suggest that patients are often not highly engaged in care decisions, and may not be aware that there are decisions in which they can be involved. This study explored emergency physicians (EPs) perceptions of their patient engagement practices. Methods: As part of a stepped-wedge randomized controlled trial, an introductory seminar was held at 15 emergency department (ED) sites in Alberta. Seminars highlighted physician-patient communication and expectation gaps documented in local studies. As part of the seminar evaluation, EPs were asked to reflect on their engagement of patients in their practice. Descriptive results are reported. Results: A total of 114 EP surveys were returned. The majority of respondents were male (68%) and nearly 40% of respondents have practiced emergency medicine for 5 years or less. Less than half of the EPs (43%) reported always or usually asking their patients about their ED visit care expectations. Approximately one-third (32%) reported always or usually checking their patients' understanding of management options (e.g., tests, treatments and/or procedures). Patients management preferences were always or usually elicited 24% of the time. Despite limited consistency in ascertaining patients' preferences, 39% of EPs indicated that they always or usually considered their patients' preferences when choosing a management plan. Half of the EPs (51%) reported that they always or usually involved their patients in decision-making. Yet, when asked whether other EPs involved their patients in decision-making, only 15% reported that they believed their fellow clinicians did this always or usually. On average, 68% of respondents believed their patients wanted to be completely or mostly involved in their ED and decision-making; however, 16% believed patients were actually completely or mostly involved in the ED care and decision-making. Conclusion: EPs agreed that patients want to be actively involved in their ED care decisions. Yet, their reflection on their own practice, and especially their perception of their colleagues', highlight large gaps between physicians' perception of what patients would like and what patients actually receive. Further research should explore these interactions in depth, understand what constrains EPs from involving patients and explore patient perceptions of these interactions.
MP08: The frequency of emergency departments visits for patients with end-of-life conditions: a call for action
S. Kirkland, M. Kruhlak, M. Garrido Clua, C. Villa-Roel, S. Couperthwaite, A. Brisebois, A. Elwi, B. O'Neil, S. Duggan, B. Rowe
Introduction: An increasing number of patients with end-stage diseases present to emergency departments (EDs) for physical, spiritual, psychological and social care. The objective of this study was to identify patients with end-stage diseases with palliative care (PC) needs and document their frequency of ED visits. Methods: This prospective cohort study was conducted in two Canadian EDs. Using a modified palliative care screening tool, volunteer ED physicians were asked to identify adult patients with end-stage, chronic conditions including cancer, chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), heart failure (HF), cirrhosis, dementia and/or progressive central nervous system (PCNS) disease. Demographic data were collected from these tools and data regarding patients' visits in both the 6 months prior to and 30 days following their index visits were collected from the ED Information System. Bivariate analyses were completed using Student's t and chi-square test. Results: A total of 663 patients with end-stage illness were identified; 338 (51%) were female and the median age was 76 (IQR: 63, 85). Cancer was the most common presentation (41%), followed by dementia (23%), COPD (16%), HF (9%), CKD (9%), PCNS disease (9%) and cirrhosis (7%). These patients made a total of 1277 visits in the 6 months prior to and 288 in the 30 days following the index visit. Patients presenting to the EDs with cancer (p = 0.001), cirrhosis (p = 0.005) and CKD (p = 0.03) were more likely to visit an ED in the 6 months prior to their index visit. In contrast, patients presenting with dementia (p < 0.0001) and PCNS disease (p = 0.02) were significantly less likely to present to an ED in the 6 months prior to their index visit. Patients presenting with cirrhosis or CKD had the highest average number of ED visits in the 6 months prior to their index visit (cirrhosis: 4.59 visits, SD: 3.8, p < 0.0001; CKD: 4.39 visits, SD: 3.8, p = 0.0001). Of these patients, those presenting with end-stage cirrhosis were significantly more likely to make a return visit to an ED within 30 days after their index visit (p = 0.014). Conclusion: Cancer is the most common condition for patients with end-stage, chronic illnesses in these EDs. Those presenting with cirrhosis or CKD are at a significantly higher risk of repeat visits to the EDs. This study has identified potential deficits in care and can serve as a baseline for future intervention studies.
P154: Exploring health care connections and transitions in care for patients presenting to emergency departments with acute wheezing illnesses
B. H. Rowe, C. Villa-Roel, M. Bhutani, S. Couperthwaite, N. Runham
Introduction: Asthma and/or chronic obstructive pulmonary disease (COPD) exacerbations often result in emergency department (ED) visits. This study examined the health-related personnel providing regular care to patients with asthma and/or COPD, as well as, explored the coordination of care between the ED and outpatient settings. Methods: Descriptive cross-sectional examination of patients presenting with asthma and/or COPD exacerbations to two EDs in Edmonton between August and December 2017. Using patient interview methods information on demographics, established health care connections and health system use was collected; information on consultations, disposition and referrals was collected through chart review methods. Results: A total of 50 patients were recruited (14 patients with asthma and 36 patients with COPD). Most of the patients with asthma were female (64%) and their median age was 36 years (interquartile range [IQR]: 29, 46); sex was evenly distributed among the patients with COPD and their median age was 68 years (IQR: 61, 78). The majority reported having a family doctor (86% of the patients with asthma and 94% of the patients with COPD). On the day of admission to the ED, 29% of the patients with asthma visited their family doctor while 42% of the patients with COPD visited their Respirologist; these doctors referred >70% of the patients to the ED. While in the ED, consultations were requested in 21% of the patients with asthma (all to Pulmonary) and in 78% of the patients with COPD (evenly divided between Medicine and Pulmonary). Transition coordinators and social workers were involved in the ED care of <15% of the patients with COPD. Most patients with asthma were discharged home (86%) and 64% of the patients with COPD were hospitalized. After discharge, 14% of the patients with asthma and 50% of the patients with COPD were referred to specialized care. Conclusion: While the study patients with asthma and COPD had different health professionals providing regular care to their respiratory conditions, they both sought care before presenting to the ED. More health professionals were involved in the ED care of patients with COPD than of those with asthma. This study provided important information to support further research projects exploring ways to effectively and efficiently improve the delivery, comprehensiveness and utilization of health care services.
P053: Characteristics and outcomes of patients seen by transition coordinators in the emergency department
L.A. Gaudet, L.D. Krebs, S. Couperthwaite, M. Kruhlak, N. Loewen, E. Zilkalns, K. Clarkson, B.H. Rowe
Introduction: Emergency Department (ED) Transition Coordinators (TC) have been introduced to many EDs. In Alberta, the EDTC role was designed to evaluate the home needs of senior patients (75 years of age) to enable safe return home after an ED visit, thereby mitigating admissions and return ED visits. The effectiveness of this role at achieving its objectives has received limited evaluation. Methods: TCs assess all ED patients 75 years old, and physicians request TC assessment for patients <75 years. The TC assessment includes completing a Transitional Assessment Referral (TAR) form that collects information on comorbidities, living arrangements, connections to community and homecare services, independence in activities of daily living (ADLs), and referrals, and disposition. Trained research staff extracted data from consecutive TARs for patients presenting during April 2017 into a REDCap database. The proportions of patients seen by TCs who were admitted, had an unplanned return to the ED within the study period, or received a new homecare referral were assessed. Categorical variables are reported as proportions; continuous variables are reported as mean and standard deviation (SD) or median and interquartile range (IQR), as appropriate. Results: In April 2017, there were 9849 visits to the ED; of these, TCs assessed 478 patients during 500 visits. The mean age was 82 (SD=11.2) and 41% were male; 22 patients presented twice during April 2017. Patients had a median of 2 (IQR: 1, 5) co-morbidities and 40 (8%) patients reported falls in the past 90 days (median=1; IQR: 1, 2). Overall, 144 (29%) patients lived in a care facility, while 204 (41%) lived at home; residence was unclear or not documented for 152 (30%). Patients reported being independent in a median of 9/14 (IQR: 3, 13) ADLs. An existing homecare connection or receipt of homecare services was documented for 185 patients (37%). Finally, 59 (12%) visits included a new or updated homecare referral, while 200 (33%) ED visits ended in admission. Conclusion: Elderly patients seen in the ED assessed by EDTCs are complex, and despite being well connected, they frequently need hospitalization. In a small proportion of cases, additional or new home care resources are required prior to ED discharge; however, few patients returned to the same ED during the one month study period. Given the high proportion of patients assessed, further evaluation of outcomes is warranted.
LO46: Sex-based differences in concussion symptom reporting and self-reported outcomes in a general adult ED population
L. A. Gaudet, L. Eliyahu, J. Lowes, J. Beach, M. Mrazik, G. Cummings, S. Couperthwaite, D. Voaklander, B. H. Rowe
Introduction: Patients with concussion frequently present to the emergency department (ED). Studies of athletes and children indicate that concussion symptoms are often more severe and prolonged in females compared with males. To-date, study of sex-based concussion differences in general adult populations have been limited. This study examined sex-based differences in concussion outcomes. Methods: Adult (>17 years) patients presenting to one of three urban EDs in Edmonton, Alberta with Glasgow coma scale score 13 within 72 hours of a concussive event were recruited by on-site research assistants. Follow-up calls at 30 and 90 days post ED discharge captured extent of PCS using the Rivermead Post-Concussion questionnaire (RPQ), effect on daily living activities measured by the Rivermead Head Injury Questionnaire (RHIQ), and overall health-related quality of life using the 12-item Short Form Health Survey (SF-12). Dichotomous and categorical variables were compared using Fishers exact test; continuous variables were compared using t-tests or Mann-Whitney tests, as appropriate. Results: Overall, 130/250 enrolled patients were female. The median age was 35 years; men trended towards being younger (median=32 years; IQR: 23, 45) than women (median=40 years; IQR: 22, 52). Compared to women, more men were single (56% vs 38% (p=0.007) and employed (82% vs 71% (p=0.055). Men and women experienced different injury mechanisms (p=0.007) with more women reporting injury due to a fall (44% vs 26%), while more men were injured at work (16% vs 7%) or due to an assault (11% vs. 3%). Men had a higher return to ED rate (13% vs. 5%; p=0.015). Women had higher RPQ scores at baseline (p<0.001) and 30-day follow-up (p=0.001); this difference was not significant by 90 days (p=0.099). While women reported on the RHIQ at 30 days that their injury affected their usual activities significantly more than men (Median=5, IQR: 0, 11 vs. median=0.5, IQR: 0.5, 7; p=0.004), both groups had similar scores on the SF-12 physical composite and mental composite scales at all three measurement points. Conclusion: In a general ED concussion population, demographic differences exist between men and women. Based on self-reported and objective outcomes, womens usual activities may be more affected by concussion and PCS than men. Further analysis of these differences is required in order to identify different treatment options and ensure adequate care and treatment of injury.
P052: Utility of data captured by transition referral forms for program evaluation and research
Introduction: Increase in functional decline of older adults after discharge from the emergency department (ED) has been reported; however, evaluations of interventions to mitigate this problem are infrequent. Data collected in the ED on older adults may document functional status, yet their utility for research is unknown. This study aimed to assess the usability of data collected by ED Transition Coordinators (EDTC) during routine assessments for functional decline research. Methods: EDTCs assess all patients 75 years old presenting to the ED and complete a standardized Transitional Assessment Referral (TAR) form that documents patients independence and daily functioning. To measure the utility of these forms for research purposes, trained research staff evaluated the TARs completed in April 2017 by TCs in the University of Alberta Hospital ED by extracting data from the TARs into a purpose-built REDCap database. Researchers selected and assessed for completeness and clarity the following variables unique to the TARs: facility vs. non-facility living, goals of care and personal directive, fall history, falls in the past 90 days, independence in 14 activities of daily living (ADLs)/instrumental activities of daily living (IADLS), community services in place, and homecare referrals for discharged patients. The proportion of TARs with data for each variable and the proportion of forms with unambiguous responses in each section are reported. Results: Overall, 500 forms were analysed; patients were 41% male with a mean age of 82 (SD=11.2). Homecare referrals, facility vs. non-facility living, and independence with 14 ADLs/IADLs were the most frequently documented variables (81%, 78%, and 79%, respectively); however for ADLs/IADLs, 59% of the 79% had one or more missing components. While fall history was reported in 301 forms (60%), only 107/301 (36%) reported the number of falls in the last 90 days. The referral to homecare variable was complete in 217/268 (81%) forms; however, 99% of files were missing data about goals of care, personal directives, and receipt of community services. Conclusion: Although some information on elderly patients is consistently reported, many of the social service/human factors associated with functional decline are not recorded. While data on the TARs may be useful for studying functional decline in the ED, exploring the barriers to form completion may improve adherence thereby increasing their research utility.
P050: A prospective cohort study to evaluate discharge care for patients with atrial fibrillation and flutter (AF/AFL)
P. Duke, S. Patrick, K. Lobay, M. Haager, B. Deane, S. Couperthwaite, C. Villa-Roel, B.H. Rowe
Introduction: Atrial fibrillation and flutter (AF/AFL) are the most common arrhythmias encountered in the emergency department (ED); however, little information exists regarding the preventive management of patients with AF/AFL by emergency physicians (EPs). This study explored whether patients with AF/AFL received the recommended thrombo-embolic (TE) prophylaxis at discharge from the ED; patients' TE risks, bleeding risks, and TE prophylaxis upon discharge from the ED were examined following assessment for symptomatic acute AF/AFL. Methods: Patients ≥18 years of age identified by the EP as having a diagnosis of acute AF/AFL confirmed by ECG were prospectively enrolled from three urban Canadian EDs. Using standardized patient enrollment forms, trained research assistants collected data on the patient's demographics, TE risk (using the CHADS2 and CHA2DS2-VASc score), bleeding risk (using the HAS-BLED score), and management both in the ED and at discharge. Treating physicians were surveyed on their use of risk scores when making TE prophylaxis decisions as well as their estimate of the patient's stroke and bleeding risk. Descriptive analyses were performed. Results: From a total of 196 patients, 62% were male and the mean age was 63 years (standard deviation [SD] ±14). Most patients had previous history of AF/AFL (71%); hypertension was documented in 40% of them and ≤10% had other risk factors (e.g., congestive heart failure, vascular disease, diabetes, previous stroke, transient ischemic attack). Based on the CHADS2 score and previous management, there was opportunity for new or revised antiplatelet/anticoagulant treatment by EPs in 19% of the patients. Consultations were requested in 28% of the patients, and the majority (89%) were discharged with anticoagulant or antiplatelet agents. EPs expressed concerns that an increased risk of falls, lack of access to facilities for INR monitoring, and significant cognitive impairment would affect their willingness to prescribe anticoagulation. Conclusion: Most patients in the ED with acute AF/AFL are receiving the recommended TE prophylaxis; however, given the significant morbidity and mortality associated with AF/AFL, improved short-term prescribing practices for anticoagulants would benefit 1 in 5 ED patients. More research on barriers to EPs prescribing anticoagulants is required to improve clinician comfort in treating this high-risk population.
P101: Quality of life in patients discharged from the emergency department with atrial fibrillation or flutter (AF/AFL): a prospective cohort study
S. Patrick, P. Duke, K. Lobay, M. Haager, B. Deane, S. Couperthwaite, C. Villa-Roel, B.H. Rowe
Introduction: Following an emergency department (ED) presentation for acute atrial fibrillation and/or flutter (AF/AFL), patients often experience anxiety, depression and impaired health-related quality of life (QoL). Emergency physicians may prescribe appropriate thrombo-embolic (TE) prophylaxis upon discharge; however, the QoL of these patients is unclear. This study measured the QoL of patients with AF/AFL following discharge to determine the factors associated with QoL. Methods: Patients ≥18 years of age identified by the attending physician as having a diagnosis of acute AF/AFL confirmed by ECG were prospectively enrolled from three Edmonton, AB EDs. Using standardized enrollment forms, trained research assistants collected data on patient demographics factors and management both in the ED and at discharge. Patients' health-related QoL was assessed up to 20 days after their initial ED visit by a telephone interview based on six domains of the short-form 8 health survey. Results: From a total of 196 enrolled patients, 121 (62%) were male and the mean age was 63 years (standard deviation ±14). Most patients had previous history of AF/AFL (71%), and emergency physicians had the opportunity to treat or revise TE prevention therapy in 19% of the patients. The majority (89%) were discharged with prescriptions for antiplatelet or anticoagulant agents, and 188 (96%) were contacted by telephone at a median of 7 days. Most patients rated their overall health between good and excellent (70%); however, 30% assessed their health as fair or very poor. Many also reported having physical limitations (54%), difficulties completing their daily work (42%), bodily pain (32%) and limitations in social activities (32%). Finally, some patients reported having low energy (25%). At follow up, patients receiving adequate TE prevention rated their health to be similar to those without adequate TE prevention (30% vs 23%; p=0.534). Conclusion: Overall, patients with acute, symptomatic AF/AFL seen in the ED have impairments in health-related QoL following discharge from the ED. Many factors contribute to this impairment; however, providing patients with appropriate TE prophylaxis at discharge did not explain these findings. Further research is required to explore the impact of AF/AFL on patient's health-related QoL after discharge from the ED.
P072: Exploring definitions of "unnecessary care" in emergency medicine: a qualitative analysis of physician survey responses
L. Krebs, L. Gaudet, L.B. Chartier, B.R. Holroyd, S. Dowling, A.H. Cheng, C. Villa-Roel, S.G. Campbell, S. Couperthwaite, B.H. Rowe
Introduction: Recently, campaigns placing considerable emphasis on improving emergency department (ED) care by reducing unnecessary tests, treatments, and/or procedures have been initiated. This study explored how Canadian emergency physicians (EPs) conceptualize unnecessary care in the ED. Methods: An online 60-question survey was distributed to EP-members of the Canadian Association of Emergency Physicians (CAEP) with valid emails. The survey explored respondents awareness/support for initiatives to improve ED care (i.e., reduce unnecessary tests, treatments and/or procedures) and asked respondents to define "unnecessary care" in the ED. Thematic qualitative analysis was performed on these responses to identify key themes and sub-themes and explore variation among EPs definitions of unnecessary care. Results: A total of 324 surveys were completed (response rate: 18%); 300 provided free-text definitions of unnecessary care. Most commonly, unnecessary ED care was defined as: 1) performing tests, treatments, procedures, and/or consults that were not indicated or potentially harmful (n=169) and/or 2) care that should have been provided within a non-emergent context for a non-urgent patient (n=143). Emergency physicians highlighted the role of system-level factors and system failures that result in ED presentations as definitions of unnecessary care (n=69). They also noted a distinction between providing necessary care for a non-urgent patient and performing inappropriate/non-evidenced based care. Finally, a tension emerged in their description of frustration with patient expectations (n=17) and/or non-ED referrals (n=24) for specific tests, treatments, and/or procedures. These frustrations were juxtaposed by participants who asserted that "in a patient-centred care environment, no care is unnecessary" (Participant 50; n=12). Conclusion: Variation in the definition of unnecessary ED care is evident among EPs and illustrates that EPs' conceptualization of unnecessary care is more nuanced than current campaigns addressing ED care improvements represent. This may contribute to a perceived lack of uptake or support for these initiatives. Further exploring EPs perceptions of these campaigns has the potential to improve EP engagement and influence the language utilized by these programs.
P071: Choosing Wisely in the emergency department: exploring the reach, support and potential for the Choosing Wisely Canada® campaign among emergency physicians
L. Krebs, L.B. Chartier, B.R. Holroyd, S. Dowling, A.H. Cheng, C. Villa-Roel, S.G. Campbell, S. Couperthwaite, B.H. Rowe
Introduction: Choosing Wisely Canada® (CWC) launched in April 2012. Since then, the Emergency Medicine (EM) top-10 list of tests, treatments and procedures to avoid has been released and initiatives are on-going. This study explored CWC awareness and support among emergency physicians. Methods: A 60-question online survey was distributed to Canadian Association of Emergency Physicians (CAEP) members with valid e-mails. The survey collected information on demographics, awareness/support for CWC as well as physicians' perceived barriers and facilitators to implementation. Descriptive statistics were performed in SPSS (Version 24). Results: Overall, 324 surveys were completed (response rate: 18%). Respondents were more often male (64%) and practiced at academic/tertiary care hospitals (56%) with mixed patient populations (74%) with annual ED volumes of >50,000 (70%). Respondents were familiar with campaigns to improve care (90%). Among these respondents, 98% were specifically familiar with CWC and 73% felt these campaigns assisted them in providing high-quality care. Respondents felt that the top-5 EM recommendations were supported by high quality evidence, specifically the first 4 recommendations (>90% each). The most frequently reported barriers to implementation were: patients' expectations/requests (33%), the possibility of missing severe condition(s) (20%), and requirements of ED consultations (12%). Potential facilitators were identified as: strong evidence-base for recommendations (37%), medico-legal protection for clinicians who adhere to guidelines (13%), and support from institutional leadership (11%). Conclusion: CWC is well-known and supported by emergency physicians. Despite the low response rate, exploring the barriers and facilitators identified here could enhance CWC's uptake in Canadian emergency departments.
LO091: Non-urgent presentations to the emergency department: patients' reasons for presentation
L. Krebs, R. Chetram, S.W. Kirkland, T. Nikel, B. Voaklander, A. Davidson, B. Holroyd, E. Cross, C. Villa-Roel, K. Crick, S. Couperthwaite, C. Alexiu, G. Cummings, D. Voaklander, B.H. Rowe
Published online by Cambridge University Press: 02 June 2016, p. S61
Introduction: Some low acuity Emergency Department (ED) presentations are considered non-urgent or convenience visits and potentially avoidable with improved access to primary care. This study explored self-reported reasons why non-urgent patients presented to the ED. Methods: Patients, 17 years and older, were randomly selected from electronic registration records at three urban EDs in Edmonton, Alberta (AB), Canada during weekdays (0700 to 1900). A 47-item questionnaire was completed by each consenting patient, which included items on whether the patient believed the ED was their best care option and the rationale supporting their response. A thematic content analysis was performed on the responses, using previous experience and review of the literature to identify themes. Results: Of the 2144 eligible patients, 1408 (65.7%) questionnaires were returned, and 1402 (65.4%) were analyzed. For patients who felt the ED was their best option (n = 1234, 89.3%), rationales included: safety concerns (n = 309), effectiveness of ED care (n = 284), patient-centeredness of ED (n = 277), and access to health care professionals in the ED (n = 204). For patients who felt the ED was not their best care option (n = 148, 10.7%), rationales included a perception that: access to health professionals outside the ED was preferable (n = 39), patient-centeredness (particularly timeliness) was lacking in the ED (n = 26), and their health concern was not important enough to require ED care (n = 18). Conclusion: Even during times when alternative care options are available, the majority of non-urgent patients perceived the ED to be the most appropriate location for care. These results highlight that simple triage scores do not accurately reflect the appropriateness of care and that understanding the diverse and multi-faceted reasons for ED presentation are necessary to implement strategies to support non-urgent, low acuity care needs.
LO100: Electrical vs chemical cardioversion in patients with acute atrial fibrillation: a multicenter parallel group randomized controlled clinical trial
F.X. Scheuermeyer, G. Andolfatto, J. Christenson, S. Couperthwaite, C. Villa-Roel, K. Lobay, B.H. Rowe
Published online by Cambridge University Press: 02 June 2016, pp. S64-S65
Introduction: Patients with atrial fibrillation (AF) of <48 hours duration often present to Emergency Departments (ED). Electrical or chemical cardioversion can be employed to restore normal sinus rhythm (NSR). Current guidelines make no recommendations between these two methods and the management decisions are left to the discretion of the treating physician. The objective of this study was to compare these two approaches in terms of ED length of stay (LOS), success (conversion to NSR) and health related outcomes. Methods: At six western Canadian EDs, eligible adult patients were assigned to one of two groups following concealed allocation and using a centralized computer-generated randomization method: electrical cardioversion (EC) first (followed by chemical cardioversion [CC] if the primary method failed) or CC first (followed by EC if the primary method failed). Baseline evaluation/interview and 3/30 day telephone contact were completed and documented using the REDCap data-platform. Adverse events were externally adjudicated in a blinded-fashion. An intention to treat analysis was performed. Results: Overall, 84 patients participated in the study (EC: 43; CC: 41); the median age was 60 years (interquartile range [IQR]: 50, 66), and 38% were female. The baseline patient characteristics in both groups were similar. The median LOS between randomization and conversion to NSR (intervention LOS) was 1.0 hrs (IQR: 0.8, 2.7) in EC vs. 3.1 hrs (IQR: 2.0, 3.9) in CC (p<0.001); more patients in EC were discharged from the ED within 4 hours than in the CC group (65% vs. 32%; p=0.002). The majority of EC patients (84%) converted to NSR after the first attempt while half of the patients did so in the CC group (49%). No differences were observed in terms of adverse events (26% vs. 24%; mostly minimal), hospitalizations (0%), and patients' health outcomes (physician/ED visits, admissions, stroke) and status (SF-8) at 3 and 30 days, in groups EC and CC groups, respectively. Conclusion: Electrical cardioversion was associated with a statistically significant and clinically meaningful reduction in the LOS when compared to cardioversion using chemical management. Similarities in the proportions of success, adverse events and health outcomes between the groups would support the use of electrical shock as the first approach for cardioversion in clinical practice.
LO087: Emergency department patients' connection to primary care providers: reasons for lack of connection
L. Krebs, S.W. Kirkland, K. Crick, C. Villa-Roel, A. Davidson, B. Voaklander, B. Holroyd, E. Cross, T. Nikel, R. Chetram, S. Couperthwaite, G. Cummings, D. Voaklander, B.H. Rowe
Introduction: Some non-urgent/low-acuity Emergency Department (ED) presentations are considered convenience visits and potentially avoidable with improved access to primary care services. This study surveyed patients who presented to the ED and explored their self-reported reasons and barriers for not being connected to a primary care provider (PCP). Methods: Patients aged 17 years and older were randomly selected from electronic registration records at three urban EDs in Edmonton, Alberta (AB), Canada. Following initial triage, stabilization, and verbal informed consent, patients completed a 47-item questionnaire. Data from the survey were cross-referenced to a minimal patient dataset consisting of ED and demographic information. The questionnaire collected information on patient characteristics, their connection to a PCP, and patients' reasons for not having a PCP. Results: Of the 2144 eligible patients, 1408 (65.7%) surveys were returned and 1402 (65.4%) were completed. The majority of patients (74.4%) presenting to the ED reported having a family physician; however, the 'closeness' of the connection to their family physician varied greatly among ED patients with the most recent family physician visit ranging from 1 hour before ED presentation to 45 years prior. Approximately 25% of low acuity ED patients reported no connection with a family physician. Reasons for a lack of PCP connection included: prior physician retired, left, or died (19.8%), they had never tried to find one (19.2%), they had recently moved to Alberta (18.0%), and they were unable to find one (16.5%). Conclusion: A surprisingly high proportion of ED patients (25.6%) have no identified PCP. Patients had a variety of reasons for not having a family physician. These need to be understood and addressed in order for primary care access to successfully contribute to diverting non-urgent, low acuity presentations from the ED.
LO015: A multi-centered regional emergency department study of renal colic management using medical expulsion therapy
E. Bristow, A. Kinnaird, T. Schuler, P. Pang, S. Couperthwaite, C. Villa-Roel, B.H. Rowe
Introduction: Patients with renal colic present frequently to the emergency department (ED). Existing literature suggests management with medical expulsion therapy (MET) may improve outcomes, especially for those with stones > 5 mm in size. This study evaluates the use of MET in the management of adult patients seen in regional EDs with a diagnosis of renal colic. Methods: A multi-centered medical chart review study was conducted in seven Edmonton-Zone EDs. Approximately 100 cases from each site were randomly selected from administrative data from the 2014 calendar year, no repeat cases were permitted. Using a standardized data collection process and trained research assistance, data were abstracted from medical charts. Medians and inter-quartile ranges (IQR), proportions, and odds ratios (OR) with 95% confidence intervals (CIs) are reported. Results: Overall, 656 patient charts were included in the review; median age was 46 years (IQR: 35, 46) and 249 (38%) were female. Few (10%) arrived by ambulance or were on MET therapy at presentation; however, many (51%) reported a previous episode of renal colic. Many (191 {29%}) received no initial ED imaging; CT (236 {36%}) was favoured over ultrasound (39 {6%}) for initial imaging, either alone or with plain radiographs (8%). Plain radiographs were frequently ordered (204 {31%}). Only 198 (31%) of charts contained documentation of the use of MET at discharge and the median duration of therapy was 10 days (IQR: 7, 14). Initiation of MET therapy did not vary based on older age (OR = 0.8; 95% CI: 0.57, 1.14); sex (OR = 0.9; 95% CI: 0.67, 1.33); resident involvement (OR = 1.1; 95% CI: 0.63, 2.0); presentation to an academic centre (OR = 1.4; 95% CI: 0.96, 1.95) or stone size (OR = 1.3; 95% CI: 0.76, 2.06). Conclusion: Management of renal colic with MET is uncommon in this region and practice variation appears driven by physician preference rather than evidence. Practice guidelines with standardized order sets are urgently needed to improve care.
P114: Considering perceptions of patients and knowledge users in the design of an emergency-based acute asthma educational trial
B.H. Rowe, C. Villa-Roel, S.R. Majumdar, S. Couperthwaite, E. Rawe, T. Nikel
Published online by Cambridge University Press: 02 June 2016, p. S116
Introduction: Educational interventions driven by the needs of users can help move evidence into practice. This study considered the perceptions of patients and knowledge users in the design of an educational intervention in acute asthma directed from Emergency Departments (EDs). Methods: A mixed methods design with two phases was used. In phase I, convenience samples of asthmatics presenting to the University of Alberta Hospital ED and primary care providers (PCPs) from Edmonton were invited to participate in a survey. Perceptions with respect to: a) an ideal local opinion leader (OL) in ambulatory asthma care; and b) content, style and delivery methods of OL educational interventions in acute asthma were collected. In phase II, focus-group discussions were conducted to further explore preferences and expectations for such interventions; self-perceived barriers and facilitators for implementation were assessed. Results: Overall, 54 patients completed the survey; 39% preferred receiving guidance from a Respirologist, 44% during their ED visit and 56% through individual discussions. In addition, 55% expressed interest in having PCP follow-up within a week of discharge. A Respirologist was identified as an OL in ambulatory asthma by 59% of the 39 responding PCPs. All expressed interest in receiving notification of their patients' ED presentation, most within a week and including diagnosis and ED/post ED-treatment. Personalized and guideline-based recommendations were considered to be the ideal content by the majority; 39% requested this guidance through an educational pamphlet faxed to their offices. In the focus groups, patients and PCPs recognized the importance of health professional liaisons in the ED to PCP transition of care; patient anxiety and time constraints were identified as potential barriers for ED-educational information uptake and proper post-ED follow-up, respectively. Conclusion: Messages arising from patients and PCPs help tailoring study interventions to meet local needs and expectations. Overall, patients and physicians are seeking ways to mitigate problems with transitions in care. This contact with the practice environment also facilitates the identification of potential determinants to implementation and knowledge uptake.


text:
One HBO Star Dares to Criticize Feminism
By Susan L.M. Goldberg 2014-12-22T12:00:42
Not every HBO woman is one of Lena Dunham's girls. Seventeen-year-old Game of Thrones star Maisie Williams made a brilliant observation about contemporary feminism in a recent interview:
We talk about actor Emma Watson's recent UN speech, in which she talked about her reasons for becoming a feminist, and the need for men to be onside; Williams says she is impatient with this kind of "first-world feminism". "A lot of what Emma Watson spoke about, I just think, 'that doesn't bother me'. I know things aren't perfect for women in the UK and in America, but there are women in the rest of the world who have it far worse."
That infuriated Salon's Jenny Kutner:
Self-identified feminist or not, Williams appears to have fallen into a trap of, well, totally taking for granted the gains western feminism has made. The assertion that the inequalities that persist in the UK and United States "don't bother her" is a milder version of women against feminism rejecting the progress wrought by the women's movement only as they bask in it.
Kutner then lists a series of first-world feminist issues that Williams and feminists everywhere are obviously required to care about: "pay inequality" (myth), "restricted reproductive healthcare access" (myth), "rape culture" (BIG myth, BIG - like Rolling Stone big) and "institutional sexism" (that creates a hostile environment for men as much, if not moreso, than women). She then uses her own big, white, first-world feminist journo privilege to paint Williams's honest observation about the inequalities within the women's movement as an example of that ugly buzzword "privilege":
https://pjmedia.com/blog/one-hbo-star-dares-to-criticize-feminism/

redpajama_set_name: RedPajamaCommonCrawl


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text:
Opining on 2017 Four Continents: On selection and timing
Emergency Opining! My Opining post was originally going to be after the completion of Four Continents, but the ladies' free skate results today warranted an extra post. It was a rollercoaster of an event for the women. When it was all said and done, the top three after the short program finished second, fourth, and eighth, and two skaters came from behind to make it onto the podium. One of those skaters was Mirai Nagasu, who skated a career-best free skate to take the bronze.
So what's the emergency? Well, Nagasu finished fourth at Nationals and was left off the World team, while US champion Karen Chen had a rough go and finished 12th. All of this set off a chorus of questions over the selection process for Worlds for Team USA. The previous season's Four Continents results are currently part of the selection criteria for the current season. There's an argument to be made for the current season's Four Continents to be used for the current season's selection criteria.
Do you make the selection after the US Championships, as US Figure Skating, Japan Skating Federation, and Skate Canada do, or do you wait until the month before Worlds like Figure Skating Federation of Russia does?
It really is not an easy answer. And certainly not as easy as it may seem.
The problem with the current methodology
As it stands, the body-of-work methodology that USFS uses has the advantage of allowing all skaters to make a case for themselves at the US Championships. Everyone is put on equal footing to compete against everyone else, and it's an apples-to-apples comparison. Plus, there is a general assumption that the US Championships are as pressure-filled as any competition gets, and thus doing well there is necessarily an indicator of doing well at Worlds or the Olympics.
One of the main issues with this process is that the team is essentially selected with almost a third of the season (two months) still left to go. And a lot can change in those two months, including a big competition like Four Continents.
Had Four Continents been part of the criteria, the dynamics of the competition we just saw would have completely changed. In Nagasu's case, in particular, this competition became something of a consolation prize because she doesn't have Worlds to worry about and no additional burden (e.g., the determination of Olympic spots) comes into play at this competition. You can argue that the change in stakes could have completely altered the landscape here. And had none of the three skaters done well, what do you do? Do you stick with the team or do you go to the next skater down at Nationals, albeit one who didn't have the burden to deliver under this pressure?
The problem with using Four Continents
And therein lies a large part of the issue with using Four Continents as a most-recent indicator. It has the potential of comparing apples to oranges because you can only send three skaters to this competition. Had Four Continents been part of the criteria, Ashley Wagner would most certainly have participated instead of opting out to increase training time. And with Wagner here, there would not have been a Nagasu breakthrough performance to compare against - simply because Nagasu would not have been able to go with three spots per country. So even if Chen and Bell performed exactly the way they did here, the fairness of comparing two skaters who faced the pressure of having to deliver at this competition against the hypothetical performance of a skater who wasn't at this competition would be completely out of whack.
Then what do you do? Do you tell one or two skaters after Nationals that their Worlds spot is secure and make Four Continents a tiebreaker for, say, the skaters who finished in third, fourth, and fifth? But then why have this skate-off here when you already had it at Nationals? It is then no longer about how a skater fares in international competition anymore; rather, it might as well just be a redo of Nationals in an international competition setting. So if there were to be a change in selection methodology, the usage of Four Continents as a criterion needs to be clear.
And just a little context to leave you with
It's important to note that the current selection methodology used by USFS, JSF, and Skate Canada is also a vestige of the days when Four Continents was not around (it began in 1999) or was a competition that many of the top skaters opted out of (until recent seasons). Should they rethink it now that Four Continents has played a bigger role in the skating world? Absolutely. But making a criteria change right now would only discredit USFS, because there was no expectation of this competition being a selection event for this year's Worlds.
And next season? Well, the US Championships are already held two weeks earlier than usual to accommodate the Olympics in mid-February (Worlds is usually at the end of March). Four Continents, incidentally, will be held in Taiwan just two weeks before the Olympics take place.
But one thing is for sure - the athletes are not the ones who should be feeling the burden of a selection process they have no control over. It is up to USFS to refine the methodology to optimize the team that eventually represents Team USA at the most important competitions of the season. Doing it retroactively would be a disservice to the team and to the athletes.
In Figure Skating, Four Continents, Rocker Analysis, Opining Tags Mirai Nagasu, Karen Chen, Mariah Bell
← 2017 Four Continents play-by-play/results: Men's free skate2017 Four Continents play-by-play/results: Ladies free skate →


text:
Taxpayers' heightened IRS penalty risk may continue through 2020
By Brittany De LeaFOXBusiness
The tax cuts were too much: Joe Lieberman
Former Sen. Joe Lieberman, (I-Ct.), on the tax reform legislation, the U.S. economy and the Federal Reserve.
The Internal Revenue Service will not release an updated W-4 form to go along with the new tax law until 2020, the Treasury Department announced on Thursday, which means taxpayers may continue to be at a heightened risk of owing a year-end tax penalty.
"Launching the redesigned form in 2020 will allow the Treasury and the IRS to properly implement changes to the withholding system and ensure taxpayers have a positive and simplified experience," Treasury Secretary Steven Mnuchin said in a statement.
For the 2019 tax season, the IRS said it will continue to use a form similar to the current W-4, which has resulted in some issues for taxpayers.
This year, employers are using W-4 forms already on file to calculate withholding amounts, which is problematic because the sweeping tax reform law changed everything from personal exemptions to the standard deduction. The Tax Cuts and Jobs Act gave the Treasury Department authority to determine the withholding allowance structure because the old method was no longer suitable, and there was not enough time to issue a new W-4.
According to a simulation conducted by the Government Accountability Office (GAO) in August, which reviewed the revised federal tax withholding tables for 2018 implemented by the IRS and the Treasury Department, 21 percent of workers are at risk of having their taxes underwithheld – 3 million more than projections based on the old tax code. These individuals will be stuck with a bill instead of a refund check come April.
Only 6 percent of taxpayers are expected to have wages accurately withheld, while 73 percent are likely to have their taxes overwithheld. The former is three percentage points less than a simulation conducted using the same withholding structure and the old tax code. Accurate withholding was assumed to be within $100 of what is truly owed.
The IRS did say on Thursday that it would be implementing changes to the form in order to make the system more accurate and more transparent.
When asked in February about how many errors the Treasury has seen so far this year, Treasury Secretary Steven Mnuchin declined to comment directly, instead urging taxpayers to use the IRS withholding calculator.
Employees can update their withholding amounts and the administration has encouraged them to use the tax calculator, available on the IRS website. The IRS recently urged older Americans to check how much was being withheld from their monthly pension and annuity checks in order to avoid a penalty next year, as part of an ongoing awareness campaign.


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Data Mill North is the open data platform for the North of England - a place for organisations to share their open data.
Listed here are information and guidance documents in respect of open data generally and guidance for publishing data. The documents are produced by Data Mill North and distributed internally and externally with Data Mill North partners.
Leeds Data Mill's quarterly newsletter published by Leeds City Council's Open Data team. Further information Got a open data story, product or idea? Get in touch at open.data@leeds.gov.uk PLEASE NOTE: DATASPEAK is now published as a regular blog rather than a quarterly newsletter. Please check the Community/Blogs section for the latest news.


text:
//
// Created by raver119 on 06.02.2018.
//

#include <graph/FrameState.h>

namespace nd4j {
    namespace graph {
        FrameState::FrameState(Nd4jLong id) {
            this->_id = id;
        }

        int FrameState::getNumberOfCycles() {
            return _numberOfCycles;
        }

        void FrameState::incrementNumberOfCycles() {
            ++_numberOfCycles;
        }

        bool FrameState::wasActivated() {
            return _activated;
        }

        void FrameState::markActivated(bool reallyActivated) {
            _activated = reallyActivated;
        }

        std::string &FrameState::getFrameName() {
            return _name;
        }

        bool FrameState::isRewindPlanned() {
            return _rewindPlanned;
        }

        int FrameState::getRewindPosition() {
            return _rewindPosition;
        }

        void FrameState::setRewindPosition(int pos) {
            _rewindPosition = pos;
        }

        void FrameState::setRewindPositionOnce(int pos) {
            if (_rewindPosition < 0)
                _rewindPosition = pos;
        }

        void FrameState::planRewind(bool reallyPlanning) {
            _rewindPlanned = reallyPlanning;
        }
    }
}

redpajama_set_name: RedPajamaGithub


Oct 23, 2015 - RENAULT s.a.s.
A method for diagnosing operation of a valve to purge a canister of an internal combustion engine, the method, carried out during a purge, including: a) detecting, at an instant to, that the purge valve is open; b) executing a forced closing of the valve at an instant t2; c) measuring a pressure P1m of the intake manifold and calculating a corresponding modelled pressure P1c, at an instant t1 between the instant t0 and the instant t2; d) measuring a pressure of the manifold P2m and calculating a corresponding modelled pressure P2c, at an instant t3 after the instant t2; e) calculating a deviation E1 between P1m and P1c and calculating a deviation E2 between P2m and P2c; f) calculating a criterion C=E1−E2; and g) diagnosing malfunction of the purge valve if the criterion C is lower than a predetermined threshold value Cs.
The present invention relates to a method for diagnosing the operation of the purge valve of a fuel vapor filter of an internal combustion-engined vehicle. The invention also relates to the engine implementing this method.
Pollution control standards currently stipulate that vehicles must be equipped with means permitting the diagnosis of the operation of the purging of the fuel vapor filter.
A suchlike filter, also referred to as a "canister", is mounted on a vehicle containing an internal combustion engine and a reservoir for fuel, such as petrol, in order to prevent any vapors emerging from this reservoir from being discharged into the atmosphere. It is regularly purged in the course of a journey and in an automatic manner. This purging takes place by establishing a circuit between an air inlet into a reserve chamber of the filter and the intake manifold of the engine, in order for the vapors to be burned in the combustion chambers along with the fuel. A purge valve is mounted on a pipe connecting the filter to the intake manifold. During normal operation, the purge valve, controlled by a control unit of the engine, opens progressively at the start of the purge, remains open until the end of the purge, and then recloses likewise progressively. The opening is progressive in order for the operating parameters of the engine to have the time to adapt to this additional arrival of fuel and air.
When this purge valve remains open, does not close again or closes again only partially, this is referred to as a malfunction.
In order to detect such malfunctions, the methods of the prior art test the operation of the purge valve when the vehicle is in idling mode.
One of the methods for diagnosing involves observing the operation of the engine during opening of the purge valve. By way of example, document FR 2 900 982 A1 proposes to perform a purge of the canister when the engine is idling, and to observe the behavior of an idling speed controller, for example based on a controller of the PID (Proportional Integral Derivative) type. A comparison of the parameters of the controller before the purge and after the purge makes it possible to diagnose whether the opening of the purge valve has or has not taken place.
Suchlike methods are not applicable, however, in the case of vehicles equipped with automatic stop and start functions (Start & Stop). The idling phases are virtually non-existent, in fact, in vehicles of this kind. It is therefore becoming necessary to develop new methods which operate outside the idling speed.
In order to respond to this need, the present invention proposes a method for diagnosing the operation of the purge valve of a canister which operates both at the idling speed and outside the idling speed.
g) diagnosing the malfunction of said purge valve if the criterion C is lower than a predetermined threshold value Cs.
Thus, the implementation of the diagnosis of the operation of the purge valve, according to the invention, is not limited to the idling phases and may be achieved at any moment when a purge is initiated. In fact, since the method is based on the modeling of the manifold pressure, it is possible to measure the prevailing pressure inside the intake manifold at any time and to compare it with a modeled pressure, obtained at the same time, which corresponds theoretically to the prevailing pressure inside the intake manifold outside the purging phases. The variation in the measured pressure in relation to the modeled pressure thus makes it possible to provide information about the opening and the closing of the purge valve.
This method is simple and does not require specific means for its implementation, other than a program, for example in the control unit for the engine. It is sufficient to detect that a purge phase is in progress, to measure the manifold pressure and, at the same time, to determine the value of the modeled pressure, and then to order a forced and instantaneous closing of said purge valve. After this closing, it is likewise necessary to measure the manifold pressure and, at the same time, to determine the value of the modeled pressure. A comparison of the deviation between the value of the measured pressure and the modeled pressure, before and after the instantaneous closing, permits any malfunction to be detected. In fact, in the case of normal operation of this purge valve, a sharp fall in the manifold pressure should follow this instantaneous closing. However, this would result in the fact that the criterion calculated by the formula C=E1−E2, where E1=E1m−E1c and E2=E2m−E2c, will be high. Conversely, in the case of a valve which does not operate correctly, that is to say which is blocked in an opening or closing position, this criterion will be low because the values of E1 and E2 will be close.
The implementation of the method does not require the installation of specific means of measurement, since a sensor permitting the measurement of the pressure inside the intake manifold is already currently available on internal combustion engines. The modeling is undertaken on the basis of conventional parameters such as, for example, without limitation, the speed of the engine, the degree of opening of a butterfly valve, the temperature of the engine, and the atmospheric pressure. In order to identify a variation in pressure due to the purge flow rate thereof caused by a change in the operating point of the engine, the model does not take into account the purge flow rate and, as a result, varies only according to the operating point of the engine.
In addition, the calculation of a difference between the deviations E1 and E2 makes it possible not to take into account a systematic deviation between the measured pressure and the modeled pressure. In fact, the systematic deviation being constant, the provision of a difference between the deviations cancels out the effect of the systematic deviation.
According to one embodiment, the level of opening from which the purge valve is considered to be sufficiently open is greater than or equal to 70% opening of said purge valve. This condition makes it possible to ensure the reliability of the measurement. In fact, the greater the level of opening of the valve, the more accurate the criterion C will be. This is explained by the fact that the flow of air and fuel vapors arriving in the intake manifold increases with the increase in the level of opening of the purge valve. As a result, the deviation between the measured pressure before the instantaneous closing and that measured after this instantaneous closing is greater. The value of the modeled pressure is independent of this level of opening, since the model varies only according to the operating point of the engine.
In addition, in order not to restrict the number of diagnoses performed in the course of a journey, it is recommended that the level of opening from which the purge valve is considered to be sufficiently open should be less than 90% opening of said purge valve.
According to a preferred embodiment, the deviation between the instant t0 and the instant t1 corresponds to a stabilization time for the manifold pressure. Thus, as soon as the opening of the purge valve is detected, at the instant to, a brief delay will be initiated until the instant t1 in order to permit the stabilization of the manifold pressure, whereupon the actual pressure P1m is measured and the corresponding modeled pressure P1c is calculated. This stabilization will permit, in particular, a more accurate value for P1m to be obtained.
Advantageously, this time between the instant t0 and the instant t1 lies between 1 s and 3 s.
According to a preferred embodiment, the deviation between the instant t2 and the instant t3 corresponds to a stabilization time for the manifold pressure following the forced and instantaneous closing. Thus, as soon as the forced and instantaneous closing has taken place, at the instant t2, a brief delay is initiated until the instant t3 in order to permit the stabilization of the manifold pressure, whereupon the actual pressure P2m is measured and the corresponding modeled pressure P2c is calculated. This stabilization will permit, in particular, a more accurate value for P2m to be obtained.
Advantageously, this time between the instant t2 and the instant t3 lies between 0.5 s and 2 s.
According to one embodiment, between the instant t0 and the instant t1, it is verified that the manifold pressure is lower than a previously determined maximum value Pmax, for example 800 hPa. It is likewise verified that the operating point of the engine is stable, by ensuring that the variation in the manifold pressure is lower than a previously determined maximum value, for example 20 hPa/s, as an absolute value.
According to another embodiment the instant t2 and the instant t3, it is also verified that the manifold pressure is lower than a previously determined maximum value Pmax and that the operating point of the engine is stable. If the variation in pressure between the instant t2 and the instant t3 exceeds a pre-established threshold, in the order of 100 hPa, the diagnosis is stopped because it is at risk of being compromised.
Preferentially, the instant t1 is equal to the instant t2, the forced and instantaneous closing of the purge valve being executed just after the recording of the measured pressure P1m and the calculated pressure P1c. The fact of initiating the instantaneous closing just after the measurement of the pressure P1m and the calculation of the pressure P1c makes it possible to reduce the time necessary for a diagnosis. The number of diagnoses possible in the course of the same purge increases as a consequence of this. This is explained by the fact that, during the instantaneous closing of the purge valve, if the control unit of the engine the purge detects that the duration of the purge was not sufficient, said purge valve will reopen automatically.
According to an improved embodiment, the steps a) to g) are repeated at least once, and a malfunction of the purge valve is concluded to exist if the criterion C on each occasion is lower than the threshold value Cs. This makes it possible to impart greater reliability to the diagnosis and limits the risks of raising false alarms. For example, if the first implementation of the diagnosis detects a malfunction, steps a) to g) are repeated a predetermined number of times, for example between 2 and 4. If, and only if, the result is the same on each occasion that these steps are repeated, the malfunctioning of the purge valve is concluded to exist.
According to another improved embodiment, the modeled pressure includes a theoretical part and a corrective part, this corrective part being determined by a learning process according to the deviation between the theoretical part and the pressure measured outside the purge phases. This learning process makes it possible to take into account systematic variabilities in relation to the theoretical model of the operation of the engine. These variabilities derive, for example, from machining inaccuracies, from the replacement of a sensor or from contamination. The corrective part is determined either globally or, preferentially, depending on at least certain parameters characterizing the operating point of the engine.
The invention also has as its object an internal combustion engine containing an intake manifold, a fuel vapor filter, a purge valve establishing a fluidic communication on request between a reserve chamber of the filter and of the engine, means of measuring a manifold pressure prevailing in the interior of the intake manifold, said engine being characterized in that it implements a method as described previously.
FIG. 2 is a time diagram showing the development of the manifold pressure, measured and modeled in the course of a purge with forced closing according to a preferred embodiment of the method.
The internal combustion engine 1 as represented in FIG. 1 is of the positive-ignition type. It contains a series of combustion chambers 10 supplied with a mixture of air and fuel through an air filter 11, followed by a butterfly valve 12 and by an intake manifold 13. Other functional elements of the engine 1 are without relevance to the invention and are not represented here.
The engine 1 includes in addition a reservoir 14 for fuel and a filter for fuel vapors 15. The filter for fuel vapors 15 contains a reserve chamber 150, which is connected via a first pipe 16 to the upper part of the reservoir 14. The reserve chamber 150 is likewise connected to an air intake 151 and to the intake manifold 13 by means of a second pipe 17 and a purge valve 152.
The engine 1 includes a control unit 18 which is, for example, an electronic microprocessor card. A suchlike control unit 18 is conventional and is not described in detail here.
The control unit 18 receives information from sensors positioned on the engine 1, in particular with a sensor for the speed of rotation of the engine crankshaft, temperature sensors, an oxygen probe, which are not represented here, and a pressure sensor 19 for measuring the pressure inside the intake manifold 13.
The control unit 18 likewise controls the purge valve 152. When a purge is controlled and lies outside the implementation of the diagnostic method according to the invention, the purge valve 152 opens progressively until it is completely open. It is kept open for a certain time and is then reclosed, likewise progressively. When the valve is open, a gas flow is established between the air intake 151 and the intake manifold 13, such that the fuel vapors contained in the reserve chamber 150 are carried towards the intake manifold 13 and are burned in the combustion chambers 10.
FIG. 2 shows the position of the purge valve 152, as a percentage of its opening, in the course of the implementation of the method according to the invention during a purge phase, as the curve 20. The change in the position of this purge valve 152 includes a phase 201 of progressive opening until total opening, a phase 202 of maintaining in the open position and an instantaneous closing 203.
During this change in the position of the purge valve 152, the control unit 18 determines a modeled pressure, which corresponds theoretically to the pressure inside the intake manifold 13 outside the purge phases. The modeled pressure is represented by the curve 21 in FIG. 2. The modeled pressure contains a theoretical part and corrective part, obtained by a learning process outside the purge periods. At the same time, the pressure sensor 19 measures the pressure inside the intake manifold 13. The result of this measurement is indicated by the curve 22 in FIG. 2.
When the purge valve 152 is blocked, the pressure measured inside the intake manifold does not change in the same way. The curve 23 represents the change in the measured pressure when the purge valve 152 is blocked in the closed position. In this case, the pressure inside the intake manifold 13 remains very close to the modeled pressure. A deviation D may exist between the modeled pressure and the measured pressure, although this deviation is substantially constant.
In order to perform a diagnosis according to the invention, the control unit 18 detects, at an instant t0, that the purge valve is open when the opening thereof reaches a certain percentage of opening beyond which the opening is considered to be sufficient. This percentage opening is preferably between 70% and 90% opening. This will make it possible both to have an accurate measurement of P1m and not to limit the number of possible diagnoses in the course of a single purge.
A first delay is then initiated in order to permit the stabilization of the pressure in the intake manifold. The duration of this delay is from is to 3 s, for example. At the end of this first delay, at the instant t1, the control unit 18 memorizes the value of the pressure P1m measured inside the manifold and the calculated value P1c for the modeled pressure according to the operating point of the engine 1. These two values will then serve to calculate a first deviation E1=P1m−P1c.
Forced and instantaneous closing of the purge valve 152 is subsequently performed at an instant t2 situated slightly after the instant t1, such that the control unit 18 has already memorized the pressure values P1m and P1c during this interval. As a variant, not represented here, the instant t2 could also be the same as the instant t1.
and the criterion C is then compared to a predetermined threshold Cs. If the criterion C is greater than Cs, the valve has functioned correctly. Otherwise, the diagnosis is repeated one or more times. If the result remains unchanged after a certain number of times, for example between 2 and 4 times, that is to say if the criterion C on each occasion is below the threshold Cs, it is then concluded that a malfunction of the purge valve 152 has occurred. If, on the other hand, the criterion C is at least once greater than the threshold Cs, it is concluded that no malfunction has taken place.
g) diagnosing malfunction of the purge valve if the criterion is lower than a predetermined threshold value.
15: The method for diagnosing as claimed in claim 14, wherein the level of opening from which the purge valve is considered to be sufficiently open is greater than or equal to 70% opening of the purge valve.
16: The method for diagnosing as claimed in claim 14, wherein the level of opening from which the purge valve is considered to be sufficiently open is less than 90% opening of the purge valve.
17: The method for diagnosing as claimed in claim 14, wherein the deviation between the instant t0 and the instant t1 corresponds to a stabilization time for the manifold pressure.
18: The method for diagnosing as claimed in claim 14, wherein the time between the instant t0 and the instant t1 is between 1 s and 3 s.
19: The method for diagnosing as claimed in claim 14, wherein the deviation between the instant t2 and the instant t3 corresponds to a stabilization time for the manifold pressure following the forced and instantaneous closing.
20: The method for diagnosing as claimed in claim 14, wherein the time between the instant t2 and the instant t3 is between 0.5 s and 2 s.
21: The method for diagnosing as claimed in claim 14, wherein, between the instant t0 and the instant t1, it is verified that the manifold pressure is lower than a previously determined maximum value Pmax and that the operating point of the engine is stable.
22: The method for diagnosing as claimed in claim 14, wherein, between the instant t2 and the instant t3, it is verified that the manifold pressure is lower than a previously determined maximum value Pmax and that the operating point of the engine is stable.
23: The method for diagnosing as claimed in claim 14, wherein the instant t1 is equal to the instant t2, the forced and instantaneous closing of the purge valve being executed just after recording of the measured pressure P1m and the calculated pressure P1c.
24: The method for diagnosing as claimed in claim 14, wherein a) to f) are repeated at least once, and a malfunction of the purge valve is concluded to exist if the criterion on each occasion is lower than the threshold value.
25: The method for diagnosing as claimed in claim 14, wherein the modeled pressure includes a theoretical part and a corrective part, the corrective part being determined by a learning process according to the deviation between the theoretical part and the pressure measured outside purge phases.
an intake manifold, a fuel vapor filter, a purge valve establishing a fluidic communication on request between a reserve chamber of the filter and of the engine, means of measuring a manifold pressure prevailing in the interior of the intake manifold, the engine implementing a method as claimed in claim 14.


Specifies how NULL values in the database appear when displaying results in Interactive SQL.
Set this option according to your preference. This value is not used when saving result sets to a file. The value used when saving to a file is specified by the output_nulls option.


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text:
Adolescent Research: Late 2019 Update on E-Cigarettes, Vaping and Teenagers
By Jim Liebelt · January 1, 2020
Published in Families, Adolescence, Alcohol-Drugs, At-Risk, Culture, Guest Posts, Technology, Teen Behaviors
"Everyone who works with kids is deeply concerned about the increase in nicotine use with kids. Vaping is not only on the increase (even with all the bad press) but it's extremely dangerous. For years, nicotine use among kids has been on the decrease. Not anymore. Vaping has changed all that. My good friend and colleauge Jim Liebelt has written an excellent on vaping that every parent must read."
Despite declines in teen cigarette use over recent years, parents should be aware that teen use of e-cigarettes has become part of today's youth culture scene. An e-cigarette is a device that turns nicotine, flavorings and other chemicals into an inhalable vapor. The use of e-cigarettes is known as "vaping," and users are known as "vapers." With the legalization of marijuana in many states, vaping solutions containing THC, the psychoactive chemical found in marijuana, are available in the marijuana marketplace. The vaping trend is drawing increased scrutiny, warnings, and crackdowns on e-cigarette sales to teens from public health experts and government agencies.
According to recent information from the Journal of the American Medical Association, 28% of high school students and 11% of middle school students have reported vaping in the previous month, more than doubling the numbers identified just three years ago. The U.S. Food and Drug Administration has called teen nicotine vaping an "epidemic," with approximately 5.3 million teenagers having used e-cigarettes.
In light of the epidemic of teen vaping, federal and state governments are scrambling to regulate, restrict, and research the vaping industry. When e-cigarettes appeared on the market in the early-2000s, little was known about the chemical make-up of vaping liquids and there were no governmental regulations. So, in a real sense, the genie was let out of the bottle without knowing much, if anything, about who the genie was. Today's challenge to local, state and federal governments is to put the genie back in the bottle. It's proving to be an extremely difficult process. The availability of vaping products has spread beyond traditional retail outlets, to off-market/black-market products that may be sold from small tobacco shops, marijuana retail stores, and can be purchased easily online.
Vaping-related lung illnesses and deaths:
In mid-2019, a surge of vaping-related lung illnesses and deaths were reported. As of October 2019, almost 1900 lung illness cases had been reported along with 37 deaths. People under the age of 24 accounted for more than half of the deaths.
Since e-cigarettes have been available since the early-2000s, the sudden onset of vaping-related illnesses and deaths seemed irregular and set government officials scrambling to find answers.
The CDC has reported that 86% of patients with vaping-related lung illnesses reported using vaping products containing THC, the psychoactive chemical found in marijuana. Initial research has suggested a culprit: vitamin E acetate found in off-market/black-market THC vaping liquids as the chemical responsible for the lion's share of vaping-related lung illnesses and deaths in the U.S.A. The chemical has not been found in branded e-cigarette vaping liquids.
Governmental reactions:
Due to the combination of concerns over youth e-cigarette use leading to nicotine addiction and the vaping-related lung illnesses and deaths, governments quickly ramped up efforts in 2019 to enact bans (to one extent or another) on the use of vaping products.
According to a WebMD online article, Are Vaping Bans the Way to Go? by Kathleen Doheny, at least nine states have taken action to restrict or ban e-cigarettes and other vaping products: California, Massachusetts, Michigan, Montana, New York, Oregon, Rhode Island, Utah, and Washington. Lawsuits challenging the bans have been filed in all of these states. Preliminary injunctions blocking the bans have been granted in some states. Only in Massachusetts, Rhode Island and Washington are vaping bans still in effect.
Globally, in September 2019, the government of India banned all aspects of the e-cigarette market including manufacturing, import, export, and sales, citing public health concerns for youths.
More research:
These days, new research findings are being frequently released. A sampling of a few of the new findings are briefly outlined below.
Many teens are unaware of nicotine in e-cigarettes. A 2019 report found that 63% of teen Juul users (the most popular e-cigarette on the market) did not know that the product contained nicotine.
E-cigarette flavors attract teens. An early-2019 study by the University of Southern California found that 9 of 10 teens involved in the study vaped fruit, candy, and other non-traditional flavors and those that vaped flavored e-cigarettes are more likely to continue vaping and to be heavy users. Another USC study found that mint e-cigarettes were the most popular flavor among teens in 2019.
One in three high school e-cigarette users have also vaped marijuana. A 2018 study which surveyed over 20,000 high school and middle school students about vaping, found that among e-cigarette users, one in three high school students and one in four middle school students had also vaped marijuana.
Teen e-cigarette use is not a gateway to smoking. A late-2019 study has suggested that adolescent e-cigarette use does not lead to tobacco smoking. The findings revealed that lifetime and current e-cigarette use did not significantly increase the risk of current conventional cigarette smoking.
What should parents know and do?
• Adolescence is a season of experimentation for teenagers. With the rise of the popularity of vaping by teens, teens are increasingly facing temptations to experiment. A teen's closest friends are extremely influential during these years of experimentation. One report from the U.S. Centers for Disease Control and Prevention and the U.S. Food and Drug Administration showed that nearly 40% of teens who use e-cigarettes led them to try vaping themselves. Parents should be proactive to know their child's friends, as these provide a window of understanding into your teen's values, behaviors, and temptations.
• Nicotine is an extremely addictive drug, and one of the most heavily used addictive drugs in the United States. It activates brain circuitry that regulates feelings of pleasure and provides the body with a "reward" sensation. Whether or teen realizes the fact or not, e-cigarettes almost always contain nicotine. The Juul device, popular among teen vapers, contains nicotine.
• While federal and state governments are scrambling to ramp up research and enact regulations pertaining to vaping products, manufacturers are still somewhat unregulated in the U.S., and many e-cigarette products are made outside of the country and imported into the country. Some product tests have shown the presence of unhealthy chemicals and metals in e-cigarette vapor, which may be dangerous when ingested by humans. And dangerous vitamin e acetate has been found in some marijuana vaping liquids, a chemical used to dilute THC content. But because of the variety of manufacturers, particularly in off-market/black-market products, it has been very difficult to scientifically determine the exact chemicals (other than nicotine) that are generally contained in the vapor.
• Other recent research has found that e-cigarette use appears to be a gateway to marijuana. Refer to the recent research noted above.
• Understand that if your teen vapes, or is interested in experimenting, they have many avenues for obtaining vaping products. Their access is not limited to walking into a traditional retail outlet. They may also have access via friends and online websites.
• Make discussing vaping a topic of discussion with your teens. Ask them about the attitudes concerning vaping among their friends and peers.
• Set clear expectations and consequences on vaping.
Jim Liebelt
Jim is Senior Writer, Editor and Researcher for HomeWord. Jim has 40 years of experience as a youth and family ministry specialist, having served over the years as a pastor, author, editor, consultant, mentor, trainer, college instructor, and speaker. Jim's HomeWord Culture Blog also appears on Crosswalk.com. Jim and his wife Jenny live in Quincy, MA.
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Students investigate symbols of the United States in this unit. They exam the Liberty Bell, the American Flag, the President, and the Bald Eagle.
Students define what a patriotic symbol means, as well as sing a patriotic song. For this social science lesson students work in groups to write about a patriotic symbol. Groups draw pictures of their symbols.
Students display knowledge of historical facts regarding the American Flag as they use creative writing skills.