콜린의 한국인 영양소 섭취기준 제정 검토를 위한 문헌 고찰 및 향후 과제 (Literature review and future tasks necessary to establish of Korean Dietary Reference Intake for choline)
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- Journal of Nutrition and Health
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- 제55권2호
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- pp.211-226
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- 2022
콜린은 세포막의 구조적 완전성, 메틸 대사, 아세틸콜린과 같은 신경전달물질 합성, 세포막 (인지질, phospholipids) 투과 신호전달, 지질 및 콜레스테롤 운반과 대사 등에 있어서 복합적으로 작용하고 있는 중요한 영양 성분이다. 콜린은 체내 합성이 가능하지만 요구량을 만족시키기에 불충분하므로 식사를 통해 섭취해야 한다. 미국/캐나다, 호주/뉴질랜드, 유럽, 중국, 대만 등에서는 콜린 충분섭취량과 상한섭취량이 제정되었으나, 일본은 콜린 데이터베이스가 구축되어 있지 않다는 이유로 콜린 Dietary Reference Intakes (DRI) 제정을 고려하고 있지 않다. 우리나라에서도 2020년 Dietary Reference Intakes for Koreans (KDRI) 제·개정 연구에서 콜린의 제정 여부를 검토하였으나 여전히 우리나라 식품을 대상으로 한 콜린 데이터베이스 구축 연구나 한국인을 대상으로 한 콜린 섭취량 조사 등의 연구가 전혀 이루어지지 않고 있어서 콜린 섭취기준의 제정은 어려운 것으로 판단하였다. 다만 2020년 DRI 개·제정을 위한 준비 작업의 일환으로 콜린 섭취량과 질병발생 가능성을 검증하기 위해 1949년부터 최근까지 보고된 문헌검색, 평가 및 문헌요약 작업을 통해 차후 콜린 DRI 제정을 위한 근거를 마련한 것은 본 사업의 성과라고 볼 수 있을 것이다. 인간을 대상으로 한 RCT, 코호트연구, 환자-대조군 연구 및 단면적 관찰 연구를 통해 충분한 양 (400-500 mg/day)의 콜린섭취는 간기능 손상 (지방간), 신경관손상, 심혈관질환 및 유방암 예방의 효과 및 인지기능 개선과 관계가 있는 것으로 판단되는 반면, 높은 수준의 콜린 섭취가 오히려 전립선암과 상관관계가 있다는 부정적인 연구결과도 있었다. 현재로서는 콜린 섭취와 건강결과와의 상관성을 결론짓기에는 연구결과들이 일관성이 부족하고 매우 제한적이고 더욱이 한국인을 대상으로 한 콜린 섭취와 건강결과와의 관련성을 조사한 논문은 전무한 실정이므로 콜린 DRI 제정을 위해서는 한국인을 대상으로 한 충분한 임상실험 결과가 뒷받침되어야 할 것이다.
데이터 센터는 컴퓨터 시스템과 관련 구성요소를 수용하기 위한 물리적 환경시설로, 빅데이터, 인공지능 스마트 공장, 웨어러블, 스마트 홈 등 차세대 핵심 산업의 필수 기반기술이다. 특히, 클라우드 컴퓨팅의 성장으로 데이터 센터 인프라의 비례적 확장은 불가피하다. 이러한 데이터 센터 설비의 상태를 모니터링하는 것은 시스템을 유지, 관리하고 장애를 예방하기 위한 방법이다. 설비를 구성하는 일부 요소에 장애가 발생하는 경우 해당 장비뿐 아니라 연결된 다른 장비에도 영향을 미칠 수 있으며, 막대한 손해를 초래할 수 있다. 특히, IT 시설은 상호의존성에 의해 불규칙하고 원인을 알기 어렵다. 데이터 센터 내 장애를 예측하는 선행연구에서는, 장치들이 혼재된 상황임을 가정하지 않고 단일 서버를 단일 상태로 보고 장애를 예측했다. 이에 본 연구에서는, 서버 내부에서 발생하는 장애(Outage A)와 서버 외부에서 발생하는 장애(Outage B)로 데이터 센터 장애를 구분하고, 서버 내에서 발생하는 복합적인 장애 분석에 중점을 두었다. 서버 외부 장애는 전력, 냉각, 사용자 실수 등인데, 이와 같은 장애는 데이터 센터 설비 구축 초기 단계에서 예방이 가능했기 때문에 다양한 솔루션이 개발되고 있는 상황이다. 반면 서버 내 발생하는 장애는 원인 규명이 어려워 아직까지 적절한 예방이 이뤄지지 못하고 있다. 특히 서버 장애가 단일적으로 발생하지 않고, 다른 서버 장애의 원인이 되기도 하고, 다른 서버부터 장애의 원인이 되는 무언가를 받기도 하는 이유다. 즉, 기존 연구들은 서버들 간 영향을 주지 않는 단일 서버인 상태로 가정하고 장애를 분석했다면, 본 연구에서는 서버들 간 영향을 준다고 가정하고 장애 발생 상태를 분석했다. 데이터 센터 내 복합 장애 상황을 정의하기 위해, 데이터 센터 내 존재하는 각 장비별로 장애가 발생한 장애 이력 데이터를 활용했다. 본 연구에서 고려되는 장애는 Network Node Down, Server Down, Windows Activation Services Down, Database Management System Service Down으로 크게 4가지이다. 각 장비별로 발생되는 장애들을 시간 순으로 정렬하고, 특정 장비에서 장애가 발생하였을 때, 발생 시점으로부터 5분 내 특정 장비에서 장애가 발생하였다면 이를 동시에 장애가 발생하였다고 정의하였다. 이렇게 동시에 장애가 발생한 장비들에 대해서 Sequence를 구성한 후, 구성한 Sequence 내에서 동시에 자주 발생하는 장비 5개를 선정하였고, 선정된 장비들이 동시에 장애가 발생된 경우를 시각화를 통해 확인하였다. 장애 분석을 위해 수집된 서버 리소스 정보는 시계열 단위이며 흐름성을 가진다는 점에서 이전 상태를 통해 다음 상태를 예측할 수 있는 딥러닝 알고리즘인 LSTM(Long Short-term Memory)을 사용했다. 또한 단일 서버와 달리 복합장애는 서버별로 장애 발생에 끼치는 수준이 다르다는 점을 감안하여 Hierarchical Attention Network 딥러닝 모델 구조를 활용했다. 본 알고리즘은 장애에 끼치는 영향이 클 수록 해당 서버에 가중치를 주어 예측 정확도를 높이는 방법이다. 연구는 장애유형을 정의하고 분석 대상을 선정하는 것으로 시작하여, 첫 번째 실험에서는 동일한 수집 데이터에 대해 단일 서버 상태와 복합 서버 상태로 가정하고 비교분석하였다. 두 번째 실험은 서버의 임계치를 각각 최적화 하여 복합 서버 상태일 때의 예측 정확도를 향상시켰다. 단일 서버와 다중 서버로 각각 가정한 첫 번째 실험에서 단일 서버로 가정한 경우 실제 장애가 발생했음에도 불구하고 5개 서버 중 3개의 서버에서는 장애가 발생하지 않은것으로 예측했다. 그러나 다중 서버로 가정했을때에는 5개 서버 모두 장애가 발생한 것으로 예측했다. 실험 결과 서버 간 영향이 있을 것이라고 추측한 가설이 입증된 것이다. 연구결과 단일 서버로 가정했을 때 보다 다중 서버로 가정했을 때 예측 성능이 우수함을 확인했다. 특히 서버별 영향이 다를것으로 가정하고 Hierarchical Attention Network 알고리즘을 적용한 것이 분석 효과를 향상시키는 역할을 했다. 또한 각 서버마다 다른 임계치를 적용함으로써 예측 정확도를 향상시킬 수 있었다. 본 연구는 원인 규명이 어려운 장애를 과거 데이터를 통해 예측 가능하게 함을 보였고, 데이터 센터의 서버 내에서 발생하는 장애를 예측할 수 있는 모델을 제시했다. 본 연구결과를 활용하여 장애 발생을 사전에 방지할 수 있을 것으로 기대된다.
실버세대의 중요성은 인구 증가뿐만 아니라 구매력의 향상 및 의사 표현의 강도가 증가하면서 더욱 커지고 있다. 이에 따라 과거 실버세대 전체를 대상으로 접근하던 마케팅 전략은 실버세대의 특성에 따라 적절히 분류하여 접근하는 방식으로 수정되는 것이 적절하다. 또한 세분군 분류 결과에 따라 고객 접근 전략이 결정되므로, 세분군이 얼마나 동일한 특성을 보유하고 있는 지는 마케팅 계획 수립에 매우 중요한 요소가 된다. 따라서 이론적으로 동일 세분군에 속해 있는 고객의 니즈는 대체로 일치해야 한다. 본 연구에서는 실버세대의 생활 행태와 생애 단계를 감안하여, 실버 세대 대상의 마케팅을 위한 세분군 (細分群) 분류를 수행하였으며, 분류된 세분군의 니즈가 얼마나 일치하고 있는지를 측정하기 위하여 동질도 (DoH: Degrees of Homogeneity)를 측정하였다. 동질도는 각 세분군을 대상으로 수행된 설문조사의 객관식 문항 별로 최다 응답자가 선택한 보기 문항이 다른 문항에 비하여 유의미하게 많다고 판단되는 문항의 수를 전체 문항의 수로 나눈 것으로 정의하였다. 본 연구는 동질도를 활용한 세분군 분류 결과의 적절성 평가 방법을 제시하였다는데 의의가 있으며, 다양한 분야에서 응용될 수 있을 것으로 판단된다. 또한 본 연구에서 제시한 실버세대 세분군 분류 결과는 점차 증가하고 있는 실버세대를 위한 마케팅 방안 수립의 기본 자료로 활용될 수 있을 것으로 판단된다.
Nursing of today has as one of its objectives the solving of problems related to human needs arising from the demands of a rapidly changing society. This nursing objective, I believe, can he attained by the appropriate application of scientific principles in the giving of comprehensive nursing care. Comprehensive nursing care may be defined as nursing care which meets all of the patient's needs. the needs of patients are said to fall into five broad categories: physical needs, psychological needs, environmental needs, socio-economic needs, and teaching needs. Most people who become ill have adjustment problems related to their new situation. Because patient teaching is one of the most important functions of professional nursing, the success of this teaching may be used as a gauge for evaluating comprehensive nursing care. This represents a challenge foe the future. A questionnaire consisting of 67 items was distributed to 200 professional nurses working ill direct patient care at Yonsei University Medical Center in Seoul, Korea. 160 (80,0%) nurses of the total sample returned completed questionnaires 81 (50.6%) nurses were graduates of 3 fear diploma courser 79 (49.4%) nurses were graduates of 4 year collegiate nursing schools in Korea 141 (88,1%) nurses had under 5 years of clinical experience in a medical center, while 19 (11.9%) nurses had more than 5years of clinical experience. Three hypotheses were tested: 1. “Nurses had high levels of concept and knowledge toward patient teaching”-This was demonstrated by the use of a statistical method, the mean average. 2. “Nurses graduating from collegiate programs and diploma school programs of nursing show differences in concepts and knowledge toward patient teaching”-This was demonstrated by a statistical method, the mean average, although the results showed little difference between the two groups. 3. “Nurses having different amounts of clinical experience showed differences in concepts and knowledge toward patient teaching”-This was demonstrated by the use of a statistical method, the mean average. 2. “Nurses graduating from collegiate programs and diploma school programs of nursing show differences in concepts and knowledge toward patient teaching”-This was demonstrated by a statistical method, the mean average, although the results showed little difference between the two groups. 3. “Nurses having different amounts of clinical experience showed differences in concepts and knowledge toward patient teaching”-This was demonstrated by the use of the T-test. Conclusions of this study are as follow: Before attempting the explanation, of the results, the questionnaire will he explained. The questionnaire contained 67 questions divided into 9 sections. These sections were: concept, content, time, prior preparation, method, purpose, condition, evaluation, and recommendations for patient teaching. 1. The nurse's concept of patient teaching: Most of the nurses had high levels of concepts and knowledge toward patient teaching. Though nursing service was task-centered at the turn of the century, the emphasis today is put on patient-centered nursing. But we find some of the nurses (39.4%) still are task-centered. After, patient teaching, only a few of the nurses (14.4%) checked this as “normal teaching.”It seems therefore that patient teaching is often done unconsciously. Accordingly it would he desirable to have correct concepts and knowledge of teaching taught in schools of nursing. 2. Contents of patient teaching: Most nurses (97.5%) had good information about content of patient teaching. They teach their patients during admission about their diseases, tests, treatments, and before discharge give nurses instruction about simple nursing care, personal hygiene, special diets, rest and sleep, elimination etc. 3. Time of patient teaching: Teaching can be accomplished even if there is no time set aside specifically for it. -a large part of the nurse's teaching can be done while she is giving nursing care. If she believes she has to wait for time free from other activities, she may miss many teaching opportunities. But generally proper time for patient teaching is in the midmorning or midafternoon since one and a half or two hours required. Nurses meet their patients in all stages of health: often tile patient is in a condition in which learning is impossible-pain, mental confusion, debilitation, loss of sensory perception, fear and anxiety-any of these conditions may preclude the possibility of successful teaching. 4. Prior preparation for patient teaching: The teaching aids, nurses use are charts (53.1%), periodicals (23.8%), and books (7.0%) Some of the respondents (28.1%) reported that they had had good preparation for the teaching which they were doing, others (27.5%) reported adequate preparation, and others (43.8%) reported that their preparation for teaching was inadequate. If nurses have advance preparation for normal teaching and are aware of their objectives in teaching patients, they can do effective teaching. 5. Method of patient teaching: The methods of individual patient teaching, the nurses in this study used, were conversation (55.6%) and individual discussion (19.2%) . And the methods of group patient teaching they used were demonstration (42.3%) and lecture (26.2%) They should also he prepared to use pamphlet and simple audio-visual aids for their teaching. 6. Purposes of patient teaching: The purposes of patient teaching is to help the patient recover completely, but the majority of the respondents (40.6%) don't know this. So it is necessary for them to understand correctly the purpose of patient teaching and nursing care. 7. Condition of patient teaching: The majority of respondents (75.0%) reported there were some troubles in teaching uncooperative patients. It would seem that the nurse's leaching would be improved if, in her preparation, she was given a better understanding of the patient and communication skills. The majority of respondents in the total group, felt teaching is their responsibility and they should teach their patient's family as well as the patient. The place for teaching is most often at the patient's bedside (95.6%) but the conference room (3.1%) is also used. It is important that privacy be provided in learning situations with involve personal matters. 8. Evaluation of patient teaching: The majority of respondents (76.3%,) felt leaching is a highly systematic and organized function requiring special preparation in a college or university, they have the idea that teaching is a continuous and ever-present activity of all people throughout their lives. The suggestion mentioned the most frequently for improving preparation was a course in patient teaching included in the basic nursing program. 9. Recommendations: 1) It is recommended, that in clinical nursing, patient teaching be emphasized. 2) It is recommended, that insertive education the concepts and purposes of patient teaching he renewed for all nurses. In addition to this new knowledge, methods and materials which can be applied to patient teaching should be given also. 3) It is recommended, in group patient teaching, we try to embark on team teaching.
온라인 게임에서의 경험을 설명하는 대부분의 이전 연구들이 플로우의 역할을 강조하고 있으며, 플로우의 선행요인과 결과요인을 밝히는데 초점을 두었다. 플로우는 온라인상의 몰입경험을 설명하는데 타당한 것으로 기존 연구에서 검증되었고 성과와 직결된다는 점에서 중요한 변수임은 분명하지만, 쾌락적 경험으로서의 온라인 게임을 설명하는 데 있어서는 부족하다. 이러한 기존 연구의 부족한 점을 보완하고자, 본 연구는 음악과 영화분야에서 연구된 쾌락적 반응 연구를 온라인 게임에 적용하여 온라인 게임에서의 다차원적인 경험과정을 보여주고자 하였다. 또한 기존에 쾌락적 반응에 관한 연구를 보완하여 감각적 반응, 상상적 반응, 분석적 반응이 감정적 반응에 주는 영향을 검증하였으며, 플로우를 대신해 쾌락적 반응들이 게임 만족에 주는 영향, 게임 만족이 충성도에 주는 영향을 규명하고자 하였다. 그리고 쾌락적 선호를 조절하거나 매개하는 변수로 알려진 지각된 복잡성에 따른 조절 영향을 확인함으로써, 자극의 차이에 따른 쾌락적 반응의 영향차이를 보지 않았던 기존연구를 확장하였다. 연구결과, 감각적 반응, 상상적 반응, 분석적 반응의 감정적 반응에 대한 유의한 영향, 각각의 쾌락적 반응의 만족에 대한 유의한 영향, 만족의 충성도에 대한 영향이 검증되었다. 그리고 이러한 영향은 지각된 복잡성이 다른 집단 별로 달랐는데, 예상한 바대로 지각된 복잡성이 높은 집단에서는 분석적 반응이 전반적으로 강한 영향을, 그리고 낮은 집단에서는 감각적 반응이 감정과 만족에 강한 영향을 주는 것으로 밝혀졌다. 연구 마지막에는 이러한 결과들에 대한 요약 및 해석, 시사점 및 한계점이 논의되었다.
유전상담이 왜 국내 의료 현장에서는 필요한 의료서비스로 제공되고 잇지 않은 지에 대한 문제점과 해결책을 모색하고자 미국과 일본에서 유전상담이 필요한 유전 의료 서비스의 일환으로 정착되는 배경과 과정을 비교 고찰하였다. 동시에 국내 유전의료서비스의 현황과 유전상담 서비스 제공에 있어서 장애가 되는 요인들을 고찰하였다. 미국의 경우에는 1970년대 초에 산전 진단이 보편화되면서 유전상담의 수요가 늘게 되어 새로운 직종의 전문 유전상담사를 양성하게 되는 계기가 되었으며, 현재 29개의 양성과정의 교육을 통해서 3,000명에 가까운 전문유전상담사가 배출되어 임상유전 의료팀의 일원으로 임상유전학 전문의의 감독 하에 유전상담을 제공하고 있으며, 21세기 유전의료시대에 요구되는 생명유전정보관리를 위해서 유전상담의 필요성과 그 역할이 확대되고 있다. 일본에서는 정부주도하에 HGP 유전체 연구사업 이후 21세기 유전의료시대의 도래를 준비하는 밀레니엄 프로젝트 차원에서 <유전의료시스템의 구축과 운영> 및 <유전 카운슬링 체제의 구축>을 위한 대규모의 연구단을 구성하여 임상유전 전문의의 제도화와 본격적인 임상유전 전문 분야의 서비스가 의료기관에 개설되는 동시에 비의사를 위한 인정 유전카운슬러의 양성과 자격에 대한 연구를 거쳐서 2003년 7개의 대학원에서 유전상담사 양성 과정이 인정되어 2012년까지 110명의 유전카운슬러 배출을 목표로 현재 100명이 넘는 유전상담사가 인증되었다. 사회적 의료 수요에 부응하는 의학유전 유관학회와 교육기관의 전문가 그룹이 선도한 미국의 유전상담사 양성 프로그램과 정부 주도 하의 시대적 의료 변화에 부응하는 연구에 전문가들의 참여로 체계적인 유전상담 프로그램개발을 정착시킨 일본의 경우, 모두 비의사 유전상담사에 의한 유전상담 서비스에 대한 보험급여 등의 제도적인 보완 없이 선행되었다는 점은 우리에게 시사하는 점이 크다고 본다. 한국의료 현장에서 유전상담 서비스가 시도되지 않는 주 장애요소로는 유전상담에 대한 이해 부족과 무관심, 국내 의료 제도 하에서 의사의 진료 수가가 너무 낮아서 그 결과 외래에서 한 환자의 진료에 할애할 수 있는 시간은 10분을 초가 할 수 없는데, 유전상담 서비스는 장시간이 소요되기 때문이다(최소30분이상). 또한, 건강보험 급여제도에서 '유전상담'을 필요한 의료 행위로 인정하지 않고 있어서 아직 code 조차 생성되어 있지 않기 때문이다. 또한, 무엇보다도 근본적인 요인으로 유전상담 서비스를 제공할 수 있는 임상유전 전문의가 절대 부족하고, 최근까지도 국내 의과대학 교육 curriculum에 유전상담을 실제적으로 이해하고 습득할 기회가 없었기 때문에 일반 의료인에게는 유전상담에 대한 이해 부족과 무관심 등이 유전상담 서비스의 걸림돌로 파악되었다. 그러나, 대한의학유전학회에서 2007년 전문가들을 대상으로 실시한 유전상담과 전문 유전상담사 수요에 대한 전국 조사 연구에서 유전의료 현장과 연구 부분에서 유전상담과 전문 유전상담사가 매우 필요하다는 것이 확인되었다. 또한, 정부는 희귀난치성질환센터 Help Line의 유전질환 정보 제공을 통해서 유전상담을 받을 것을 권고하고 있지만, 실제로 의료 현장에서는 유전상담이 제공되고 있지 않기 때문에, 한국근육장애인협회, 저신장장애인협회, 코헴회등, 유전성환자들로 구성된 국내 자조회 등에서는 유전상담의 필요성을 제기하며, 서비스를 요구해오고 있다. 최근 한국희귀질환재단에서 유전성 희귀질환 환자와 가족들에게 유전상담 교육 강좌를 제공한 후 설문조사에 응한 283명의 81%가 이전에 유전상담에 대해서 접해 본 적이 없었고, 96%에서 유전상담이 희귀난치성질환 환자에게 도움이 될 것이라고 응답했다. 한편, 2009년 실시한 국내 실정에 맞는 유전상담사 양성을 위한 교육 프로그램과 교육기관의 인정 및 전문 자격 인증제도 수립에 대한 연구에서 관련 업무 전문 종사자 총 117명(의사52명, 전문 연구원30명, 간호대학 교수 26명 포함) 중 설문조사에 응한 88%가 대한의학유전학회에서 주관하고 유전상담위원회를 구성하여 교육 프로그램 개발과 인증제도를 구체화 할 것을 촉구하였다. 전문 인력의 양성을 위한 교육 수련 및 인증 프로그램을 개발하고 수행하는 것은 전문학회의 역할인 동시에 "사회적책임"이라고 생각한다. 새로운 분야(신기술)의 전문 임상 인력을 양성하는 데는 시간이 걸리기 때문에(유전상담사의경우, 2년의 대학원 과정과1년의clerkship, 임상수련과정 등으로 적어도 3년) 대한의학유전학회에서는 전문 유전상담사 양성을 위한 선 교육, 후 제도적 보완을 추진하는 것이 바람직한 방향이다. UNESCO에서는 이미 1995년 Report에서 유전상담은 유전자 검사의 보급이 증가하고 있는(21세기 유전의료시대) 의료현장에서 가장 빠르게 성장하고 있는 전문 분야로서 유전정보와 기법을 환자 진료에 연결하는 것을 돕는다고 하였다. 유전상담은 21세기 post-genome의 맞춤의료시대에서 그 역할과 적응범위가 확대되어가는 유전의료서비스의 일환이라는 것을 국내 의료계와 정부 의료 정책 부서에서 인지할 필요가 있다. 특히, 국내 저진료 수가의 의료정책 제도 하에서는 의사가 환자를 위해 충분한 진료시간을 확보하기 힘든데, 비의사전문유전상담사를유전의료팀의일원으로 유전상담에 참여하게 함으로써 환자와 가족들에게 정확한 유전정보에 대한 충분한 이해를 통해서 맞춤 유전 의료 서비스를 원활하고 효율적으로 제공하는데 도움이 될 것이다. 이를 위해서는 국내에서도 종합적인 유전의료 서비스의 구축 사업의 일환으로 유전상담 서비스 공급을 위한 전문 인력(유전상담사포함) 수급에 대한 지원 사업과 유전상담에 대한 건강보험 급여 인정 등 제도적인 뒷받침이 필요하다.
The objective of this research is to test the feasibility of developing a statewide truck traffic forecasting methodology for Wisconsin by using Origin-Destination surveys, traffic counts, classification counts, and other data that are routinely collected by the Wisconsin Department of Transportation (WisDOT). Development of a feasible model will permit estimation of future truck traffic for every major link in the network. This will provide the basis for improved estimation of future pavement deterioration. Pavement damage rises exponentially as axle weight increases, and trucks are responsible for most of the traffic-induced damage to pavement. Consequently, forecasts of truck traffic are critical to pavement management systems. The pavement Management Decision Supporting System (PMDSS) prepared by WisDOT in May 1990 combines pavement inventory and performance data with a knowledge base consisting of rules for evaluation, problem identification and rehabilitation recommendation. Without a r.easonable truck traffic forecasting methodology, PMDSS is not able to project pavement performance trends in order to make assessment and recommendations in the future years. However, none of WisDOT's existing forecasting methodologies has been designed specifically for predicting truck movements on a statewide highway network. For this research, the Origin-Destination survey data avaiiable from WisDOT, including two stateline areas, one county, and five cities, are analyzed and the zone-to'||'&'||'not;zone truck trip tables are developed. The resulting Origin-Destination Trip Length Frequency (00 TLF) distributions by trip type are applied to the Gravity Model (GM) for comparison with comparable TLFs from the GM. The gravity model is calibrated to obtain friction factor curves for the three trip types, Internal-Internal (I-I), Internal-External (I-E), and External-External (E-E). ~oth "macro-scale" calibration and "micro-scale" calibration are performed. The comparison of the statewide GM TLF with the 00 TLF for the macro-scale calibration does not provide suitable results because the available 00 survey data do not represent an unbiased sample of statewide truck trips. For the "micro-scale" calibration, "partial" GM trip tables that correspond to the 00 survey trip tables are extracted from the full statewide GM trip table. These "partial" GM trip tables are then merged and a partial GM TLF is created. The GM friction factor curves are adjusted until the partial GM TLF matches the 00 TLF. Three friction factor curves, one for each trip type, resulting from the micro-scale calibration produce a reasonable GM truck trip model. A key methodological issue for GM. calibration involves the use of multiple friction factor curves versus a single friction factor curve for each trip type in order to estimate truck trips with reasonable accuracy. A single friction factor curve for each of the three trip types was found to reproduce the 00 TLFs from the calibration data base. Given the very limited trip generation data available for this research, additional refinement of the gravity model using multiple mction factor curves for each trip type was not warranted. In the traditional urban transportation planning studies, the zonal trip productions and attractions and region-wide OD TLFs are available. However, for this research, the information available for the development .of the GM model is limited to Ground Counts (GC) and a limited set ofOD TLFs. The GM is calibrated using the limited OD data, but the OD data are not adequate to obtain good estimates of truck trip productions and attractions .. Consequently, zonal productions and attractions are estimated using zonal population as a first approximation. Then, Selected Link based (SELINK) analyses are used to adjust the productions and attractions and possibly recalibrate the GM. The SELINK adjustment process involves identifying the origins and destinations of all truck trips that are assigned to a specified "selected link" as the result of a standard traffic assignment. A link adjustment factor is computed as the ratio of the actual volume for the link (ground count) to the total assigned volume. This link adjustment factor is then applied to all of the origin and destination zones of the trips using that "selected link". Selected link based analyses are conducted by using both 16 selected links and 32 selected links. The result of SELINK analysis by u~ing 32 selected links provides the least %RMSE in the screenline volume analysis. In addition, the stability of the GM truck estimating model is preserved by using 32 selected links with three SELINK adjustments, that is, the GM remains calibrated despite substantial changes in the input productions and attractions. The coverage of zones provided by 32 selected links is satisfactory. Increasing the number of repetitions beyond four is not reasonable because the stability of GM model in reproducing the OD TLF reaches its limits. The total volume of truck traffic captured by 32 selected links is 107% of total trip productions. But more importantly, ~ELINK adjustment factors for all of the zones can be computed. Evaluation of the travel demand model resulting from the SELINK adjustments is conducted by using screenline volume analysis, functional class and route specific volume analysis, area specific volume analysis, production and attraction analysis, and Vehicle Miles of Travel (VMT) analysis. Screenline volume analysis by using four screenlines with 28 check points are used for evaluation of the adequacy of the overall model. The total trucks crossing the screenlines are compared to the ground count totals. L V/GC ratios of 0.958 by using 32 selected links and 1.001 by using 16 selected links are obtained. The %RM:SE for the four screenlines is inversely proportional to the average ground count totals by screenline .. The magnitude of %RM:SE for the four screenlines resulting from the fourth and last GM run by using 32 and 16 selected links is 22% and 31 % respectively. These results are similar to the overall %RMSE achieved for the 32 and 16 selected links themselves of 19% and 33% respectively. This implies that the SELINICanalysis results are reasonable for all sections of the state.Functional class and route specific volume analysis is possible by using the available 154 classification count check points. The truck traffic crossing the Interstate highways (ISH) with 37 check points, the US highways (USH) with 50 check points, and the State highways (STH) with 67 check points is compared to the actual ground count totals. The magnitude of the overall link volume to ground count ratio by route does not provide any specific pattern of over or underestimate. However, the %R11SE for the ISH shows the least value while that for the STH shows the largest value. This pattern is consistent with the screenline analysis and the overall relationship between %RMSE and ground count volume groups. Area specific volume analysis provides another broad statewide measure of the performance of the overall model. The truck traffic in the North area with 26 check points, the West area with 36 check points, the East area with 29 check points, and the South area with 64 check points are compared to the actual ground count totals. The four areas show similar results. No specific patterns in the L V/GC ratio by area are found. In addition, the %RMSE is computed for each of the four areas. The %RMSEs for the North, West, East, and South areas are 92%, 49%, 27%, and 35% respectively, whereas, the average ground counts are 481, 1383, 1532, and 3154 respectively. As for the screenline and volume range analyses, the %RMSE is inversely related to average link volume. 'The SELINK adjustments of productions and attractions resulted in a very substantial reduction in the total in-state zonal productions and attractions. The initial in-state zonal trip generation model can now be revised with a new trip production's trip rate (total adjusted productions/total population) and a new trip attraction's trip rate. Revised zonal production and attraction adjustment factors can then be developed that only reflect the impact of the SELINK adjustments that cause mcreases or , decreases from the revised zonal estimate of productions and attractions. Analysis of the revised production adjustment factors is conducted by plotting the factors on the state map. The east area of the state including the counties of Brown, Outagamie, Shawano, Wmnebago, Fond du Lac, Marathon shows comparatively large values of the revised adjustment factors. Overall, both small and large values of the revised adjustment factors are scattered around Wisconsin. This suggests that more independent variables beyond just 226; population are needed for the development of the heavy truck trip generation model. More independent variables including zonal employment data (office employees and manufacturing employees) by industry type, zonal private trucks 226; owned and zonal income data which are not available currently should be considered. A plot of frequency distribution of the in-state zones as a function of the revised production and attraction adjustment factors shows the overall " adjustment resulting from the SELINK analysis process. Overall, the revised SELINK adjustments show that the productions for many zones are reduced by, a factor of 0.5 to 0.8 while the productions for ~ relatively few zones are increased by factors from 1.1 to 4 with most of the factors in the 3.0 range. No obvious explanation for the frequency distribution could be found. The revised SELINK adjustments overall appear to be reasonable. The heavy truck VMT analysis is conducted by comparing the 1990 heavy truck VMT that is forecasted by the GM truck forecasting model, 2.975 billions, with the WisDOT computed data. This gives an estimate that is 18.3% less than the WisDOT computation of 3.642 billions of VMT. The WisDOT estimates are based on the sampling the link volumes for USH, 8TH, and CTH. This implies potential error in sampling the average link volume. The WisDOT estimate of heavy truck VMT cannot be tabulated by the three trip types, I-I, I-E ('||'&'||'pound;-I), and E-E. In contrast, the GM forecasting model shows that the proportion ofE-E VMT out of total VMT is 21.24%. In addition, tabulation of heavy truck VMT by route functional class shows that the proportion of truck traffic traversing the freeways and expressways is 76.5%. Only 14.1% of total freeway truck traffic is I-I trips, while 80% of total collector truck traffic is I-I trips. This implies that freeways are traversed mainly by I-E and E-E truck traffic while collectors are used mainly by I-I truck traffic. Other tabulations such as average heavy truck speed by trip type, average travel distance by trip type and the VMT distribution by trip type, route functional class and travel speed are useful information for highway planners to understand the characteristics of statewide heavy truck trip patternS. Heavy truck volumes for the target year 2010 are forecasted by using the GM truck forecasting model. Four scenarios are used. Fo~ better forecasting, ground count- based segment adjustment factors are developed and applied. ISH 90 '||'&'||' 94 and USH 41 are used as example routes. The forecasting results by using the ground count-based segment adjustment factors are satisfactory for long range planning purposes, but additional ground counts would be useful for USH 41. Sensitivity analysis provides estimates of the impacts of the alternative growth rates including information about changes in the trip types using key routes. The network'||'&'||'not;based GMcan easily model scenarios with different rates of growth in rural versus . . urban areas, small versus large cities, and in-state zones versus external stations. cities, and in-state zones versus external stations.
Much has teed changed in the field of hospital administration in the It wake of the rapid development of sciences, techniques ana systematic hospital management. However, we still have a long way to go in organization, in the quality of hospital employees and hospital equipment and facilities, and in financial support in order to achieve proper hospital management. The above factors greatly effect the ability of hospitals to fulfill their obligation in patient care and nursing services. The purpose of this study is to determine the optimal methods of standardization and quality nursing so as to improve present nursing services through investigations and analyses of various problems concerning nursing administration. This study has been undertaken during the six month period from October 1971 to March 1972. The 41 comprehensive hospitals have been selected iron amongst the 139 in the whole country. These have been categorized according-to the specific purposes of their establishment, such as 7 university hospitals, 18 national or public hospitals, 12 religious hospitals and 4 enterprise ones. The following conclusions have been acquired thus far from information obtained through interviews with nursing directors who are in charge of the nursing administration in each hospital, and further investigations concerning the purposes of establishment, the organization, personnel arrangements, working conditions, practices of service, and budgets of the nursing service department. 1. The nursing administration along with its activities in this country has been uncritical1y adopted from that of the developed countries. It is necessary for us to re-establish a new medical and nursing system which is adequate for our social environments through continuous study and research. 2. The survey shows that the 7 university hospitals were chiefly concerned with education, medical care and research; the 18 national or public hospitals with medical care, public health and charity work; the 2 religious hospitals with medical care, charity and missionary works; and the 4 enterprise hospitals with public health, medical care and charity works. In general, the main purposes of the hospitals were those of charity organizations in the pursuit of medical care, education and public benefits. 3. The survey shows that in general hospital facilities rate 64 per cent and medical care 60 per-cent against a 100 per cent optimum basis in accordance with the medical treatment law and approved criteria for training hospitals. In these respects, university hospitals have achieved the highest standards, followed by religious ones, enterprise ones, and national or public ones in that order. 4. The ages of nursing directors range from 30 to 50. The level of education achieved by most of the directors is that of graduation from a nursing technical high school and a three year nursing junior college; a very few have graduated from college or have taken graduate courses. 5. As for the career tenure of nurses in the hospitals: one-third of the nurses, or 38 per cent, have worked less than one year; those in the category of one year to two represent 24 pet cent. This means that a total of 62 per cent of the career nurses have been practicing their profession for less than two years. Career nurses with over 5 years experience number only 16 per cent: therefore the efficiency of nursing services has been rated very low. 6. As for the standard of education of the nurses: 62 per cent of them have taken a three year course of nursing in junior colleges, and 22 per cent in nursing technical high schools. College graduate nurses come up to only 15 per cent; and those with graduate course only 0.4 per cent. This indicates that most of the nurses are front nursing technical high schools and three year nursing junior colleges. Accordingly, it is advisable that nursing services be divided according to their functions, such as professional, technical nurses and nurse's aides. 7. The survey also shows that the purpose of nursing service administration in the hospitals has been regulated in writing in 74 per cent of the hospitals and not regulated in writing in 26 per cent of the hospitals. The general purposes of nursing are as follows: patient care, assistance in medical care and education. The main purpose of these nursing services is to establish proper operational and personnel management which focus on in-service education. 8. The nursing service departments belong to the medical departments in almost 60 per cent of the hospitals. Even though the nursing service department is formally separated, about 24 per cent of the hospitals regard it as a functional unit in the medical department. Only 5 per cent of the hospitals keep the department as a separate one. To the contrary, approximately 12 per cent of the hospitals have not established a nursing service department at all but surbodinate it to the other department. In this respect, it is required that a new hospital organization be made to acknowledge the independent function of the nursing department. In 76 per cent of the hospitals they have advisory committees under the nursing department, such as a dormitory self·regulating committee, an in-service education committee and a nursing procedure and policy committee. 9. Personnel arrangement and working conditions of nurses 1) The ratio of nurses to patients is as follows: In university hospitals, 1 to 2.9 for hospitalized patients and 1 to 4.0 for out-patients; in religious hospitals, 1 to 2.3 for hospitalized patients and 1 to 5.4 for out-patients. Grouped together this indicates that one nurse covers 2.2 hospitalized patients and 4.3 out-patients on a daily basis. The current medical treatment law stipulates that one nurse should care for 2.5 hospitalized patients or 30.0 out-patients. Therefore the statistics indicate that nursing services are being peformed with an insufficient number of nurses to cover out-patients. The current law concerns the minimum number of nurses and disregards the required number of nurses for operation rooms, recovery rooms, delivery rooms, new-born baby rooms, central supply rooms and emergency rooms. Accordingly, tile medical treatment law has been requested to be amended. 2) The ratio of doctors to nurses: In university hospitals, the ratio is 1 to 1.1; in national of public hospitals, 1 to 0.8; in religious hospitals 1 to 0.5; and in private hospitals 1 to 0.7. The average ratio is 1 to 0.8; generally the ideal ratio is 3 to 1. Since the number of doctors working in hospitals has been recently increasing, the nursing services have consequently teen overloaded, sacrificing the services to the patients. 3) The ratio of nurses to clerical staff is 1 to 0.4. However, the ideal ratio is 5 to 1, that is, 1 to 0.2. This means that clerical personnel far outnumber the nursing staff. 4) The ratio of nurses to nurse's-aides; The average 2.5 to 1 indicates that most of the nursing service are delegated to nurse's-aides owing to the shortage of registered nurses. This is the main cause of the deterioration in the quality of nursing services. It is a real problem in the guest for better nursing services that certain hospitals employ a disproportionate number of nurse's-aides in order to meet financial requirements. 5) As for the working conditions, most of hospitals employ a three-shift day with 8 hours of duty each. However, certain hospitals still use two shifts a day. 6) As for the working environment, most of the hospitals lack welfare and hygienic facilities. 7) The salary basis is the highest in the private university hospitals, with enterprise hospitals next and religious hospitals and national or public ones lowest. 8) Method of employment is made through paper screening, and further that the appointment of nurses is conditional upon the favorable opinion of the nursing directors. 9) The unemployment ratio for one year in 1971 averaged 29 per cent. The reasons for unemployment indicate that the highest is because of marriage up to 40 per cent, and next is because of overseas employment. This high unemployment ratio further causes the deterioration of efficiency in nursing services and supplementary activities. The hospital authorities concerned should take this matter into a jeep consideration in order to reduce unemployment. 10) The importance of in-service education is well recognized and established. 1% has been noted that on the-job nurses. training has been most active, with nursing directors taking charge of the orientation programs of newly employed nurses. However, it is most necessary that a comprehensive study be made of instructors, contents and methods of education with a separate section for in-service education. 10. Nursing services'activities 1) Division of services and job descriptions are urgently required. 81 per rent of the hospitals keep written regulations of services in accordance with nursing service manuals. 19 per cent of the hospitals do not keep written regulations. Most of hospitals delegate to the nursing directors or certain supervisors the power of stipulating service regulations. In 21 per cent of the total hospitals they have policy committees, standardization committees and advisory committees to proceed with the stipulation of regulations. 2) Approximately 81 per cent of the hospitals have service channels in which directors, supervisors, head nurses and staff nurses perform their appropriate services according to the service plans and make up the service reports. In approximately 19 per cent of the hospitals the staff perform their nursing services without utilizing the above channels. 3) In the performance of nursing services, a ward manual is considered the most important one to be utilized in about 32 percent of hospitals. 25 per cent of hospitals indicate they use a kardex; 17 per cent use ward-rounding, and others take advantage of work sheets or coordination with other departments through conferences. 4) In about 78 per cent of hospitals they have records which indicate the status of personnel, and in 22 per cent they have not. 5) It has been advised that morale among nurses may be increased, ensuring more efficient services, by their being able to exchange opinions and views with each other. 6) The satisfactory performance of nursing services rely on the following factors to the degree indicated: approximately 32 per cent to the systematic nursing activities and services; 27 per cent to the head nurses ability for nursing diagnosis; 22 per cent to an effective supervisory system; 16 per cent to the hospital facilities and proper supply, and 3 per cent to effective in·service education. This means that nurses, supervisors, head nurses and directors play the most important roles in the performance of nursing services. 11. About 87 per cent of the hospitals do not have separate budgets for their nursing departments, and only 13 per cent of the hospitals have separate budgets. It is recommended that the planning and execution of the nursing administration be delegated to the pertinent administrators in order to bring about improved proved performances and activities in nursing services.