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Agronomic Characteristics and Productivity of Winter Forage Crop in Sihwa Reclaimed Field (시화 간척지에서 월동 사료작물의 초종 및 품종에 따른 생육특성 및 생산성)

  • Kim, Jong Geun;Wei, Sheng Nan;Li, Yan Fen;Kim, Hak Jin;Kim, Meing Joong;Cheong, Eun Chan
    • Journal of The Korean Society of Grassland and Forage Science
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    • v.40 no.1
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    • pp.19-28
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    • 2020
  • This study was conducted to compare the agronomic characteristics and productivity according to the species and varieties of winter forage crops in reclaimed land. Winter forage crops used in this study were developed in National Institute of Crop Science, RDA. Oats ('Samhan', 'Jopung', 'Taehan', 'Dakyung' and 'Hi-early'), forage barley ('Yeongyang', 'Yuyeon', 'Yujin', 'Dacheng' and 'Yeonho'), rye ('Gogu', 'Jogreen' and 'Daegokgreen') and triticale ('Shinyoung', 'Saeyoung', 'Choyoung', 'Sinseong', 'Minpung' and 'Gwangyoung') were planted in the reclaimed land of Sihwa district in Hwaseong, Gyeonggi-do in the autumn of 2018 and cultivated using each standard cultivation method, and harvested in May 2019(oat and rye: 8 May, barley and triticale: 20 May.) The emergency rate was the lowest in rye (84.4%), and forage barley, oat and triticale were in similar levels (92.8 to 98.8%). Triticale was the lowest (416 tiller/㎡) and oat was the highest (603 tiller/㎡) in tiller number. Rye was the earliest in the heading date (April 21), triticale was April 26, and oat and forage barley were in early May (May 2 and May 5). The plant height was the highest in rye (95.6 cm), and triticale and forage barley was similar (76.3 and 68.3cm) and oat was the lowest (54.2 cm). Dry matter(DM) content of rye was the highest in the average of 46.04% and the others were similar at 35.09~37.54%. Productivity was different among species and varieties, with the highest dry matter yield of forage barley (4,344 kg/ha), oat was similar to barley, and rye and triticale were lowest. 'Dakyoung' and 'Hi-early' were higher in DM yield (4,283 and 5,490 kg/ha), and forage barley were higher in 'Yeonho', 'Yujin' and 'Dacheng' varieties (4,888, 5,433 and 5,582 kg/ha). Crude protein content of oat (6.58%) tended to be the highest, and TDN(total digectible nutrient) content (63.61%) was higher than other varieties. In the RFV(relative feed value), oats averaged 119, while the other three species averaged 92~105. The weight of 1,000 grain was the highest in triticale (43.03 g) and the lowest in rye (31.61 g). In the evaluation of germination rate according to the salt concentration (salinity), the germination rate was maintained at about 80% from 0.2 to 0.4% salinity. The correlation coefficient between germination and salt concentration was high in oat and barley (-0.91 and -0.92) and lowest in rye (-0.66). In conclusion, forage barley and oats showed good productivity in reclaimed land. Adaptability is also different among varieties of forage crops. When growing forage crops in reclaimed land, the selection of highly adaptable species and varieties was recommended.

Development and application of prediction model of hyperlipidemia using SVM and meta-learning algorithm (SVM과 meta-learning algorithm을 이용한 고지혈증 유병 예측모형 개발과 활용)

  • Lee, Seulki;Shin, Taeksoo
    • Journal of Intelligence and Information Systems
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    • v.24 no.2
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    • pp.111-124
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    • 2018
  • This study aims to develop a classification model for predicting the occurrence of hyperlipidemia, one of the chronic diseases. Prior studies applying data mining techniques for predicting disease can be classified into a model design study for predicting cardiovascular disease and a study comparing disease prediction research results. In the case of foreign literatures, studies predicting cardiovascular disease were predominant in predicting disease using data mining techniques. Although domestic studies were not much different from those of foreign countries, studies focusing on hypertension and diabetes were mainly conducted. Since hypertension and diabetes as well as chronic diseases, hyperlipidemia, are also of high importance, this study selected hyperlipidemia as the disease to be analyzed. We also developed a model for predicting hyperlipidemia using SVM and meta learning algorithms, which are already known to have excellent predictive power. In order to achieve the purpose of this study, we used data set from Korea Health Panel 2012. The Korean Health Panel produces basic data on the level of health expenditure, health level and health behavior, and has conducted an annual survey since 2008. In this study, 1,088 patients with hyperlipidemia were randomly selected from the hospitalized, outpatient, emergency, and chronic disease data of the Korean Health Panel in 2012, and 1,088 nonpatients were also randomly extracted. A total of 2,176 people were selected for the study. Three methods were used to select input variables for predicting hyperlipidemia. First, stepwise method was performed using logistic regression. Among the 17 variables, the categorical variables(except for length of smoking) are expressed as dummy variables, which are assumed to be separate variables on the basis of the reference group, and these variables were analyzed. Six variables (age, BMI, education level, marital status, smoking status, gender) excluding income level and smoking period were selected based on significance level 0.1. Second, C4.5 as a decision tree algorithm is used. The significant input variables were age, smoking status, and education level. Finally, C4.5 as a decision tree algorithm is used. In SVM, the input variables selected by genetic algorithms consisted of 6 variables such as age, marital status, education level, economic activity, smoking period, and physical activity status, and the input variables selected by genetic algorithms in artificial neural network consist of 3 variables such as age, marital status, and education level. Based on the selected parameters, we compared SVM, meta learning algorithm and other prediction models for hyperlipidemia patients, and compared the classification performances using TP rate and precision. The main results of the analysis are as follows. First, the accuracy of the SVM was 88.4% and the accuracy of the artificial neural network was 86.7%. Second, the accuracy of classification models using the selected input variables through stepwise method was slightly higher than that of classification models using the whole variables. Third, the precision of artificial neural network was higher than that of SVM when only three variables as input variables were selected by decision trees. As a result of classification models based on the input variables selected through the genetic algorithm, classification accuracy of SVM was 88.5% and that of artificial neural network was 87.9%. Finally, this study indicated that stacking as the meta learning algorithm proposed in this study, has the best performance when it uses the predicted outputs of SVM and MLP as input variables of SVM, which is a meta classifier. The purpose of this study was to predict hyperlipidemia, one of the representative chronic diseases. To do this, we used SVM and meta-learning algorithms, which is known to have high accuracy. As a result, the accuracy of classification of hyperlipidemia in the stacking as a meta learner was higher than other meta-learning algorithms. However, the predictive performance of the meta-learning algorithm proposed in this study is the same as that of SVM with the best performance (88.6%) among the single models. The limitations of this study are as follows. First, various variable selection methods were tried, but most variables used in the study were categorical dummy variables. In the case with a large number of categorical variables, the results may be different if continuous variables are used because the model can be better suited to categorical variables such as decision trees than general models such as neural networks. Despite these limitations, this study has significance in predicting hyperlipidemia with hybrid models such as met learning algorithms which have not been studied previously. It can be said that the result of improving the model accuracy by applying various variable selection techniques is meaningful. In addition, it is expected that our proposed model will be effective for the prevention and management of hyperlipidemia.

Purchasing Status and Supplier Performance Evaluation of School Foodservice in Chanwon, Korea (창원시 학교급식 식재료 구매 실태 및 공급업체 수행도 평가)

  • Jung, Hoi-Jung;Kim, Hyun-Ah
    • Journal of the Korean Society of Food Science and Nutrition
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    • v.41 no.6
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    • pp.861-869
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    • 2012
  • This study was conducted to investigate the purchasing status and to compare supplier performance evaluations between competitive bidding and negotiated contracts in school foodservice in Changwon, Korea. A total of 190 questionnaires were distributed and 167 (return rate 87.9%) were collected from June 29 to September 28, 2010, and then a total of 151 (analysis rate 79.5%) were used for the final analysis. First, 91.4% of food product purchases for school meals were contracted through competitive bidding, especially limited competitive bidding. It mainly consisted of agricultural products, processed food, and eco-friendly agricultural products (fruit). Second, 78.8% of schools purchased food products by negotiated contracts, while single negotiation accounted for 59.7%. Food products by negotiated contract consisted of meat, kimchi, and fish. Third, the purchase status of competitive bidding and negotiated contracts showed a significant difference in agricultural products (p<0.001), fish (p<0.001), meats (p<0.001), poultry (p<0.001), antibiotic-free poultry (p<0.001), eco-friendly grain (p<0.001), eco-friendly agricultural products (fruit) (p<0.001), eco-friendly processed food (p<0.001), processed products (p<0.001), milk (p<0.001) and general grain (p<0.001) except for kimchi. Fourth, comparative analysis of supplier performance evaluation (on a 5-point Likert scale) of school foodservice showed that price of product of competitive bidding (3.73) was significantly higher than that of negotiated contract (2.95) (p<0.001), and the overall performance level of the negotiated contract (3.85) was significantly higher than that of competitive bidding (3.61) (p<0.01). The supplier performance evaluation levels of product packaging (p<0.01), product quality at the time of delivery (p<0.001), hygiene of products (p<0.001), consistency to specification (p<0.001), swiftness of return and exchange (p<0.001), emergency delivery (p<0.001), service of delivery staff (p<0.05), and handling of complaints (p<0.001) of negotiated contracts were significantly higher than those of competitive bidding of school foodservice. In conclusion, school foodservice selected food suppliers both by adopting competitive bidding and negotiated contracts. And there was a significant difference of school foodservice supplier performance between competitive bidding and negotiated contracts in Changwon, Korea.

Clinical Results and Risk Factor Analysis of Surgical Treatment for Esophageal Perforation (식도천공의 수술적 치료의 임상결과와 위험인자 분석)

  • Cho, Sung-Woo;Hong, Ki-Woo;Kim, Shin;Lee, Hee-Sung;Kim, Hyoung-Soo;Lee, Jae-Woong;Choi, Goang-Min;Shin, Yoon-Cheol;Shin, Ho-Seung;Lee, Won-Yong
    • Journal of Chest Surgery
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    • v.41 no.3
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    • pp.347-353
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    • 2008
  • Background: Esophageal perforation is an emergency that. requires early diagnosis and effective treatment. A delay in diagnosis and treatment. significantly increases morbidity and mortality. Material and Method: Thirty-seven patients with esophageal perforation were surgically treated at our institutions between January 1990 and December 2006. We retrospectively reviewed the results of surgical treatment for esophageal perforation to understand the risk factors affecting survival inpatients. Result: Patients ranged in age from 21 to 87 years, with an average age of $52.7{\pm}16.98$ years. Thirty-one of the patients were men and six were women. There were 23 patients (62%) with spontaneous perforations, 10 patients (27%) with a traumatic perforation, and 4 patients (11%) with an iatrogenic perforation. The site of esophageal perforation was the cervical esophagus in 5 patients, the thoracic esophagus in 31 patients, and the abdominal esophagus in one patient. Twenty-nine patients underwent primary closure of the perforation and five patients had T-tube drainage. Exclusion-diversion procedures were performed in two patients and an esophagectomy was performed in one patient. There were six cases of mortality (16.22%) and 25 cases of postoperative complications in 15 patients (40.5%). Patients that were treated later than 24 hours after detection of the perforation showed a statistically significant high morbidity and mortality rate (p<0.05). Conclusion: The most important risk factor of esophageal perforation was the time interval between detection of the perforation and the initiation of treatment. A prompt diagnosis and effective treatment are necessary to decrease morbidity and mortality.

A Study on the Utilization Level of Traditional Medicine by Residents - On the basis of Use of Folk Medical Techniques - (주민(住民)의 전통의술(傳統醫術) 이용도(利用度) 조사연구(調査硏究) - 민속요법(民俗療法) 이용(利用)을 중심(中心) 으로 -)

  • Kim, Jin-Soon
    • Journal of agricultural medicine and community health
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    • v.13 no.1
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    • pp.3-18
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    • 1988
  • The general objective of this research is to study behavioral pattern of health care utilization and to measure the level of utilization of the traditional medicine. The specific objective is to study utilization pattern and content of folk medicine which is the indegenous medical technology recognized part of traditional medicine. This research was under taken to generate valid information that will provide basis data for formulating general direction for health education activities and for designing service package for general population. A social survey method was employed to obtain required information for the research activities, The survey field team consisted of 20 surveyors who all participated is an intensive 2 day training course. A total of 3091 households were visited and interviewed by the field team during the period 7 September to 6 October 1987. The major findings obtained from the information collected by the field survey are as follows ; 1) General characteristics of the study households 2562 households out of 3091 households visited were selected for final data process, 80.2 of the selected households were nuclear families ; 17.4%, extended families ; others 2.4%. Only 4.3 percent of the study population in the urban households indicated "no schooling" whereas 14.2% of the rural household members falls within this category. Study population in the urban areas are more protected against diseases by the national medical insurance system than those in rural areas. In their self appraisal of living standard, those who responded with low group are 39.6% and 50.3% respectively by urban and rural households. 2) Morbidity status Period prevalence rate for all diseases during the preceding 15 days before the date of the household interview v as 243,0 per 1,000 study population. For cases with the illness duration of within 15 days, the initial points of medical entry were diversied ; 56.9%, drug stores ; 30.9%, clinics and hospitals ; 4.6% folk medicine ; 1.7% clinics of Korean oriental medicine. Among the chronic case; with illness duration of over 90 days, 34.6% of these people utilized clinics and hospitals of modern medicine ; 31.6%, drug stores ; 18.6% clinics of Korean oriental medicine ; 6.8% folk medical techniques. Noticeable is the almost ten fold increase from the mere 0.9% in the utilization of Korean oriental medicine, whereas in the utilization of folk medicine, it is short of two-fold increase. 3) Folk medicine and its utilization Households that use folk medicine for relief and care of signs and symptoms commonly encountered in daily life, number 1969 households, which accounts for 76.9% of all the study households. This rather high level use of folk medicine is not different from rural to urban areas. The order of frequency of utilizing folk medicine among the study people are : the highest 14.3% for the relief of indigestion ; 8.6% for burns ; 5.1% for common cold ; 4.7% for hiccough ; and 4.2% for hordeolum. A present various procedures of folk medicine is being used to relieve all kinds of symptoms. 192 symptoms are identified at present. The most frequently used procedures of folk medicine appear to be based either on principles of the Korean oriental medicine or of scientific knowledge. Based on these survey findings, proposals for utilizing folk medicine are as follows First, this survey's findings will be feed back to both on the job training and on the spot guidance of community health practitioners, public health nurses and other peripheral work force in the health field, who are in daily contacts with community. This feed back will assure that the health personnel carry out their health education and information activities that are based on the utilization pattern of folk medicine as found in the survey result. Second, studies will be soon implemented that are designed to measure the efficiency and potency of these procedures and to improve these procedures of folk medicine were most frequently used by the community. Third, studies will continue to systematize medicinal plants and skills of Korean oriental medicine that are easily available at minimal cost in daily life for the prevention of diseases and management of emergency cases.

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The In-hospital Clinical Outcomes of Extracorporeal Life Support after Adult Cardiovascular Surgery (성인 심혈관 수술 후 시행한 체외순환보조의 조기 임상결과)

  • Yie, Kil-Soo;Na, Chan-Young;Oh, Sam-Sae;Kim, Jae-Hyun;Ryu, Se-Min;Park, Sung-Min;Cho, Seong-Joon
    • Journal of Chest Surgery
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    • v.42 no.4
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    • pp.464-472
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    • 2009
  • Background: We analyzed the clinical results and the factors for survival of patients who underwent extracorporeal life support system after adult cardiovascular surgery. Material and Method: We retrospectively reviewed the medical record of 44 patients (1.6% of the total adult cardiovascular surgical cases) who underwent the use of a ventricular assisted device or extracorporeal membrane oxygenation from January 2002 to August 2008. There were 32 (72.7%) males and their mean age was 61.7$\pm$14.9(range: 20$\sim$73) years old. The mean duration of extracorporeal life support system was 5.3$\pm$3.0 (range: 1$\sim$12) days. Result: Of these 44 patients, 24 (54.5%) patients were successfully weaned from the extracorporeal device. Eighteen (40.9%) survivors were able to be discharged from the hospital. Complications were noted in 38 patients (86.4%). An emergency operation, no usage of a concomitant intraaortic balloon pump and major complications during use of the extra corporeal life support system such as bleeding, flow instability and renal failure were identified as significant risk factors for poor survival on univariated analysis. Owing to educational support and a continuous renal replacement therapy system, the clinical outcomes of these patients have improved since 2006. On multivariated analysis, renal failure and bleeding during extracorporeal life support were significant risk factors for poor survival. Conclusion: Although using. extracorporeal life support systems after adult cardiovascular surgery revealed acceptable clinical results, determining the optimal treatment strategy and further well designed larger studies are needed to improve the survival rate of patients who undergo extracorporeal life support after adult cardiovascular surgery.

Surgical Treatment for Chronic Peptic Ulcer with Gastric Outlet Obstruction (만성 소화성 궤양에 합병된 위출구 폐색의 수술적 치료)

  • Lee, Jei Hee;Yang, Shi Joon;Jeon, Young Woong;Park, Sei Hyeog;Kim, Jong Heung;Park, Jong Min
    • Journal of Gastric Cancer
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    • v.8 no.3
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    • pp.160-165
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    • 2008
  • Purpose: With the introduction of H. pylori eradication and proton pump inhibitor, the operative treatments for the acute or chronic complications of peptic ulcer, such as perforation, bleeding and stricture, have decreased. Also owing to the development of non-operative treatment such as interventional endoscopic treatment, the surgical approach to the acute complications, like perforation and bleeding, has diminished. The non-operative treatments for the stricture and obstruction of chronic peptic ulcer in part related to discontinuation of medication have not been satisfactory. We analyzed the clinical outcomes of the patients who underwent operative treatment for outlet obstruction with peptic ulcer. Materials of Methods: From January 1994 to December 2007, we reviewed 31 patients who had been operated on at the National Medical Center for peptic ulcer obstruction. We excluded the cases of adhesive obstructions that were caused by a former ulcer operation and also the cases of obstructions found during emergency operations for treating perforation and bleeding. We classified the surgical treatment group into the bypass operation group and the surgical resection group. We evaluated the effects of the operations by the Visick score. The recurrences were confirmed only by the endoscopic observation of peptic ulcer. Results: The number of patients in the bypass operation group was 6 (19.4%) and that of resection group was 25 (80.6%). The mean age was 57.5 (25~81) years. The number of male patients was 29 (93.5%) and the number of females was 2 (6.5%). The mean symptom duration was 29.6 months. There were 19 smokers (61.3%), 6 NSAID users (19.4%) and 7 H. pylori positive patients (22.6%). Two patients underwent endoscopic balloon dilatation with no success. The locations of lesion were the stomach, the duodenum and both in 9, 20 and 2 cases, respectively. There were operative complications in 13 cases (41.9%), recurrent ulcers in 2 cases (6.5%), and reoperations in 4 cases. The mean Visick score was 1.8 (1~4). There were no statistically significant clinicopathologic differences between the bypass operation group and the resection group. The two groups had 1 case each of recurrence. Although the bypass group had a greater complication rate (83.3%) than the resection group (32%), this was not statistically meaningful (P=0.175). The mean Visick score was 3.0 in the bypass group and 1.6 in the resection group, so the resection group was better (P=0.001). Conclusion: For a case of chronic peptic ulcer with outlet obstruction, even though it has been reported that endoscopic balloon dilatation worked well, surgery is still regarded as an important treatment. If you consider the patients' satisfaction and the difficulty of diagnosing malignant ulcers, surgical resection should be recommended more often than a bypass operation.

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Factors Related to the Development of Myocardial Ischemia During Mechanical Ventilation (인공 호흡기 적용에 따른 심근 허혈의 발생에 관한 연구)

  • Kim, Tae-Hyung;Kim, You-Ho;Lim, Chae-Man;Kim, Won;Shim, Tae-Sun;Lee, Sang-Do;Kim, Woo-Sung;Kim, Dong-Soon;Kim, Won-Dong;Koh, Youn-Suck
    • Tuberculosis and Respiratory Diseases
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    • v.46 no.5
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    • pp.645-653
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    • 1999
  • Introduction : Although myocardial ischemia tends to occur more frequently than can he documented in ventilated patients, it has not been well studied on the factors related to the occurrence of the ischemia. Methods : To investigate the related factors to ischemia development, a prospective study was done in 95 cases with consecutive 73 patients who had received mechanical ventilation(MV) in MICU. In addition to 24 h holter monitoring, echocardiogram, electrolytes, cardiac enzymes, hemodynamic, and gas exchange measurements were done within 24 h after initiation of MV in 69 cases. The measurements were repeated at weaning period in 26 cases. The ischemia was defined by the ST segment changes; up-sloping depression more than 1.5 mm or down-sloping or horizontal depression more than 1.0 mm from isoelectric baseline for 80 ms following J point. Results : Twelve patients(12.6% in 95 cases) developed ischemia in total. The incidence of ischemia development showed an increased tendency in the initial 24 hr after MV (15.9%) and in patients with left-sided heart failure found by echocardiogram (18.2%) compared with that of the weaning period (3.8%) and patients without heart failure (10.9%) (P=0.12, P=0.09, in each). There were no differences in APACHE III score, baseline ECG findings, electrolytes abnormalities, use of inotropics or bronchodilators, presence of sepsis or shock, mode of ventilation, and survival rate according to the development of ischemia. Maximal heart rates and mean arterial pressure also were not different between patients with ($137.2{\pm}30.9/min$, $82.5{\pm}15.9$ mm Hg) and without ischemia ($l29.5{\pm}29.7/min$, $83.8{\pm}17.6$ mm Hg). Conclusion : Although the incidence of myocardial ischemia was 12.6% in total, there were no clinically predictable factors to the development of ischemia during mechanical ventilation.

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Clinical Study of Childhood Accidents from a Hospital Over Ten Years with Regard to Foreign Body Aspiration (단일병원에서 관찰한 최근 10년간의 소아 우발사고에 관한 연구 : 이물흡인을 중심으로)

  • Kim, Cheol-Min;Song, Jun-Young;Kim, Ja Hyung;Kim, Ki Soo;Hong, Soo-Jong
    • Clinical and Experimental Pediatrics
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    • v.45 no.9
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    • pp.1134-1140
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    • 2002
  • Purpose : Childhood accidents have been increasing recently. Accidents rank as the leading cause of childhood mortality and morbidity. We performed this study to evaluate the causes of childhood accidents. Methods : The authors analysed retrospectively the medical records of 6,410 cases of childhood accidental injuries who visited the emergency room of Asan Medical Center from January 1990 to December 1999. Results : The most common type of accidents was trauma which accounted for 5,038 cases of the total accidents, followed by falls, burns, foreign body aspiration, and poisoning. The most common age of foreign body aspiration was under two years old and the male to female ratio was 2 to 1. The most common site of foreign body aspiration was the esophagus and the stomach, followed by the respiratory tract. In airways, the right and left main bronchus were the most common site for foreign body aspiration and were accompanied by the highest mortality. The most common foreign body in the gastrointestinal tract and respiratory tract were coins and peanuts, respectively. Conclusion : The most common cause of accidents was trauma, followed by falls, burns, foreign body aspiration, and poisoning. The incidence of foreign body aspiration and poisoning is increasing in infants. In cases of foreign bodies in airways, proper management is needed because of the high mortality rate.

Quality and Affecting Factor of Care for Patients Hospitalized with Pneumonia (폐렴 입원환자 진료과정의 질적 수준과 이에 영향을 미치는 요인: 임상질지표를 중심으로)

  • Moon, Sangjun;Lee, Jin-Seok;Kim, Yoon;You, Sun-Ju;Choi, Yun-Kyoung;Suh, Soo Kyung;Kim, Yong-Ik
    • Tuberculosis and Respiratory Diseases
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    • v.66 no.4
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    • pp.300-308
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    • 2009
  • Background: The quality of care for patients with community acquired pneumonia needs to be improved; the factors affecting this care need to be analyzed. The objectives of this study were used to measure the performance of care processes of for patients with pneumonia and to determine those patient and hospital characteristics are associated with quality care. Methods: The analysis was performed using data from 21 hospitals that had over 500 beds for 1,001 patients, who were sampled randomly. All patients were born before 31 December 1989, and discharged between the two months' August 2006 and October 2006. Performance process indicators were measured by respective hospital, and multivariate logistic regression was used to calculate associations between patients and hospital characteristics using 4 process indicators. Results: Performance rates in timely assessment of oxygenation assessments and blood cultures, correct administration of antibiotic medications, and blood culture performed prior to initial antibiotics were 69.4%, 79.1%, 82.5% and 60.5%, respectively. Age had a positive affect on oxygenation assessment within 24 hours. Bed number, number of nurses per bed, annual number of emergency department visits, average percentage of beds filled, location and arrival time, and site were factors associated with process indicators. Conclusion: It is necessary to make up for the weak points in the process of care for patients with community acquired pneumonia, by enforcing quality assurance. To reduce performance rate variation among hospitals, improvement in care protocols is required for hospitals that have poor quality of care levels.