MEETING AND COMMITTEE UPDATES SEPT 2017-JAN 2018

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MEETING AND COMMITTEE UPDATES

SEPT 2017-JAN 2018

Membership
As of October 1st, 2017 we had 348 members registered in our chapter. As of January 1st, 2019 we have 370 members. That’s 100 more than last year. If anyone wants to change chapter membership status, one must call or email National directly or wait for their renewal notice.

Awards & Certification
Awards were given at the fall kickoff and recognized in the Fall Newsletter. Award nomination forms are available and we will be needing nominees by August 1st for their involvement during this past year. Recognize those that do outstanding work or are rising stars with a nomination!

Bylaws & Policies
The bylaws were updated to match National wording change “NLDC” to just “Nominating Committee.”  Also our quoram was reduced from 8% to 5% at business and chapter meetings. National recommends 3-5%. With a growing chapter and low attendance at meetings, it was difficult to get items passed. The bylaws were finally approved at the December meeting and sent to National Headquarters along with the Chapter Accountability Standards for the year.

Community Relations
See the article in the newsletter for complete community relations update.

Education & Workshops
The Fall Kickoff, Fall Workshop, and 50th Anniversary celebration in December were all very well attended. Incentive and grant monies from National helped to offset costs for these events.

The February thaw meeting is Saturday, Feb 10th on Opiate Crisis in America. March 12th topic will be on positioning
(it was requested from the Fall Workshop evaluation).

The Spring Workshop is Saturday, April 14th on Transgender Concerns
(4 CH), registration required. May meeting will be a vendor presentation. The Fall workshop (5 CH) is planned for Nov 10th with Vangie Dennis.

Finance
Beginning balance of $20,953.98 at the start of the financial year (July 1st) Ending balance on February 9th is $17,714.79. Income sources are Chapter dues, national incentives, vendor fair, silent auction, gift card raffle, workshop and kickoff registrations, and stereoscope ad sales. Chapter expenses are related to speaker fees, workshop and event costs, laptop purchase for the chapter, awards, delegate checks, and community relations efforts. All delegate checks have been processed. Ten delegates each received $1100 towards EXPO in New Orleans 2018. The Chapter also donates $1 for every member to the AORN Foundation annually; therefore, a check for $350 was sent in December 2017.  A donation of $100 will be sent to the EXPO Silent Auction.

Nominating Committee
The Nominating Committee has reviewed the candidates and completed the ballot for 2018-19. You will find the complete ballot and brief bios on each candidate in this issue. Nominations needed to be completed by February, posted to the chapter in March, approved in April, and new officers installed in May this year. June will be the transitional board meeting. Caroline Ness will move to President Elect and Jane Oksnevad will finish her term on the Board.

Legislative
The MN Legislature is status quo. Anne Jones has contributed several articles to this newsletter from HealthCare Reform to what is on the agenda at National. Anne will also be working with our December speaker, Georgie Dinghoff-Hogenson on the statewide circulator bill. AORN National does not have MN on the agenda for this topic. This will be a 1-3 year strategy. Thank you!

Newsletter & Communication
Deadline for the Summer newsletter is June10th. Four companies continue advertising with us. We have recruited a new advertisement with Irrisept this year! Scanlan continues to electronically send the Stereoscope out to the majority of members and a small mailing list to hospitals and ASCs and members who have not submitted an email to National. FaceBook has grown to 102 members! This is a closed group. Message Leah VanGorp to join!

New business
Three members will attend the Leadership Meeting at EXPO on Saturday from 8-11. They are Caroline Ness, Stacy Johnson, and Denise Edelman. Chapter Accountability standards were submitted and accepted on December 30th, 2017. Rorie would like to thank everyone for their help with all the activities so far this year. Any pictures from celebrations can be given to Anne Jones. Michelle Nolander no longer works for AORN National due to restructuring. She is working as the Director of a Denver ASC.[/vc_column_text][/vc_column_inner][/vc_row_inner][/vc_column][vc_column width=”1/4″][vc_widget_sidebar sidebar_id=”main-sidebar”][/vc_column][/vc_row]

2018-2019 Ballot for AORN Chapter #2401 of the Twin Cities

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2018-2019 Ballot for AORN Chapter #2401
of the Twin Cities

President

Denise Edelman (1 year term)
We support each other by being active in our chapter and organization. Over the years I have been involved with the board and worked closely with Rorie, our president, this past year to prepare me for my new role. I feel I have skills and knowledge to offer and also to learn. Thank you for this opportunity to support our great chapter as President as we continue to grow and improve.

President-Elect

Caroline Ness (1 year term)
I first joined AORN in 1986.
I have had the opportunity to attend Expo four times, three times as a Twin Cities chapter delegate in 2015, 2016, and 2018. I obtained my CNOR in 2013. When I was invited to the chapter meeting to recognize those earning their CNOR, I made the decision it was time to get more involved in the chapter. Prior to my involvement in the Twin Cities chapter, I served as secretary of the Bismarck and Fargo chapters. Within #2401, I’ve served in several roles: secretary, newsletter editor, co-chair of the communication committee and board of directors. In 2015, I received the Rising Star Membership Award. I am also a Certified Administrator Surgery Center (CASC). Besides managing a Surgery Center and my AORN role, I am on the Board of Directors for the Chaska Rotary. I would be honored to serve the chapter as President Elect this coming year.

Secretary

Leah VanGorp (2 year term)
I became a nurse in 2004 and obtained a job in the OR in 2011 after working in the ICU, telemetry and ER. I joined AORN and obtained my CNOR in 2014 (thanks to my mentor and co-worker, Jane Oksnevad). My OR career started at Unity Hospital as a staff nurse. Currently, I’m working as a staff nurse at M Health ASC at the University of Minnesota. I attended the AORN National Conference & Expo twice as a delegate in 2017 & 2018. I have been on the Nominating Committee for the last two years and helped expand our social media presence for our AORN chapter on Facebook, Instagram, and Twitter.
In 2016, I received the Promising Clinical Star Award. I find being involved in AORN gives me a deeper connection to my career by allowing me to continue learning with peers and colleagues outside of my job. I look forward to taking on the challenge of Secretary for our local AORN chapter.

Board of Directors

Jane Oksnevad (1 year term)
I joined AORN in 2005.
I have held several positions including Board of Directors, President elect, President, and nominating committee. I was also the Awards chair for several years and I have attended the Surgical Conference a few times. I have worked at Unity Hospital for many years as a staff nurse and orienting new employees. I have gained much through AORN like enhanced leadership, networking, and service.
I look forward to serving on the Board of Directors for one year to complete Caroline’s term.

Dick Hebrink (2 year term)

I have worked at St. Joseph’s Hospital since 1980, spent 10 years in SPD as an Assistant, Supervisor, and Asst. Manager before becoming a nurse in 1990. I transitioned to the OR in 2007 and joined AORN right away, and obtained my CNOR in 2009. I recognize the importance of Certification and what it means. I have been active nationally in many nursing arenas.
I attend local educational opportunities and encourage co-workers to do the same.

I try to galvanize my peers to pursue CNOR. Connecting and networking with others is important. I have created two bulletin boards in the OR to promote AORN. I also announce all events and educational opportunities during staff huddles. I believe AORN provides us with a lot of opportunities and being involved helps to elevate our practice. I will be attending my first EXPO this year and look forward to serving on the Board of Directors.

Nominating Committee

Melissa (Missy) Domogalla  (2 year term)
I became an OR RN at Park Nicollet Methodist Hospital in 2013. I received my CNOR certification in 2015. In 2016, I assisted with the opening of the Maple Grove – Park Nicollet ASC. In May 2017, a FT position at Cambridge Allina opened up. I have attended 3 AORN conferences, Chicago, Los Angeles, and this year in New Orleans. My passion is the operating room, but I have cross-trained to the PACU, and I like the variety this opportunity brings. This year I signed up with CCI to be a certification coach for those interested in obtaining the CNOR status. I’m looking forward to meeting more of our Chapter members and serving on the NC.

Ruth Mitchell (2 year term)
I’ve been a nurse since 1977. I transitioned to the OR in 1988. This OR was an all RN OR. My boss and the educator went to Congress in Texas and presented about our Preceptor program (ever since then I have wanted to be a member of AORN), My roles in the OR include: scrubbing, circulating, working charge both in the hospital/ASC setting, teaching new peri-op nurses, being the ENT coordinator and educator, assistant nurse manager in a level one trauma center, and an infection prevention nurse in an ASC. I became a member of AORN in 2017 and my goals are to become certified and to attend congress.

I believe in providing quality, efficient and safe care and that the circulator needs to be an RN and the voice for our patients. I look forward to serving on the NC.[/vc_column_text][/vc_column][vc_column width=”1/4″][vc_widget_sidebar sidebar_id=”main-sidebar”][/vc_column][/vc_row]

Do you have Moral Courage?

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Read more

Vaginal Mesh

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Healing Touch in a Hospital Setting

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Healing Touch in a Hospital Setting

Presented at the AORN of Twin Cities Fall Workshop, November 4th, 2017
By Greg Falvey, RN, BSN, BC HTP-A
Article written by Stacy Johnson

The objectives of the presentation were to describe Healing Touch (HT), incorporate evidence based practice, describe the relevance to nursing and include personal stories. HT is an energy therapy. Healing touch practitioners consciously use their hands in a heart-centered and intentional way to enhance, support and facilitate physical, emotional, and spiritual health and self healing.

Healing Touch utilizes light or near-body touch to clear, balance and energize the human energy system in an effort to promote healing for the whole person, mind, body and spirit. The goal of HT is to accelerate the patient’s own healing processes by restoring balance in the energy system of the patient and of the environment. HT can be incorporated in Holistic nursing practice. Using their hands in an intentional way, an HT practitioner can affect a patient’s energy field to promote self-healing and well-being.

Nursing literature describes many benefits of HT to patients. HT may provide the nurse with another resource that can be used in conjunction with pharmacologic therapy to decrease pain and anxiety for postoperative Total Knee patients. In this study, HT was used to promote relaxation, accelerate wound healing, diminish depression, and increase a patient’s sense of well-being. Clients reported a statistically significant reduction of stress after HT, and one month after surgery, 95% of the HT group felt their pain was adequately controlled, compared with 87% of the group that received standard therapy during their hospital stay.

Another study aimed at improving physical and psychological symptoms caused or arising from energy imbalances in the body. Reported benefits of HT include: reducing anxiety, increasing relaxation, decreasing pain, diminishing depression, and increasing a sense of well-being. While no significant decrease in the use of pain or anti-emetic medication was observed (many of which were scheduled), significant differences were noted in anxiety scores and length of hospital stay compared to the control group.

Our presenter works as the night shift RN in a metro hospital PACU. When there are no patients in the PACU, he assists in other units in the hospital. He has been trained as an HT practitioner, and his manager approves his use of HT as an integrative therapy. He presented personal stories where he has been able to improve care to patients using HT. Examples included reducing patient’s fear and anxiety related to surgery and more effective pain control.

Following the presentation, several HT practitioners and HT students were present to provide HT to the workshop attendees. All volunteers were able to experience a healing touch session.

 

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Community Relations Update

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Community Relations Update

Submitted by Mary Kay Boell RN

I want to give a big thank you and a shout out to our chapter members! Thank you for your financial donations and time given to the organizations our chapter supports. Here is the latest contributions update for community relations:

September – We collected
$291.00 for Second Harvest Heartland. Our donation was matched by Excel Energy creating a $582.00 donation that will feed many families in our communities.

October – We collected for Feed My Starving Children. We collected $125.00. As many of you are aware, it is an organization that turns hunger into hope for malnourished children throughout the world. Thank you for your financial support and volunteer hours spent at FMSC packing sites. Groups attended two locations: Coon Rapids and Eagan.

November – Our donation’s supported the Marine Toys for Tots program. We collected 35 toys. Thank you for helping less fortunate children enjoy a little Christmas Joy.

December – We collected monetary and food donations for The Ronald McDonald house.The monetary donation of $201.00 is much appreciated. The cash donation will help to stock the pantry. We will be serving lunch at RMH, cook for kids program after the February 10th meeting.

February – At the February meeting our monetary collection will support The American Heart Association.

March – Our donations will go to Dakota Woodlands, a transitional housing for woman and children in Dakota County.

May – Our last chapter meeting of the year, donations will be collected for Mobile Lunch Box. The Mobile Lunch Box program is operated by Open Door Pantry in Eagan. It serves summer lunch boxes and provides some activities to school age children in need in Dakota County.

It is never too late to become involved with Community Relations. Ideas and suggestions are always welcomed![/vc_column_text][/vc_column][vc_column width=”1/3″][vc_wp_custommenu nav_menu=”11″][/vc_column][/vc_row]

No Foley-ing Around: Preventing CAUTI in Surgery Patients

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No Foley-ing Around: \

Preventing CAUTI in Surgery Patients

Presented at the AORN of Twin Cities Fall Workshop, November 4th, 2017
By Stacy Johnson, MS, APRN, CNS, CNOR, CNS-CP & Ellie Carter, CLS, MPH, CIS Infection Preventionist
Article written by Stacy Johnson

This presentation discussed the impact of catheter-associated urinary tract infection (CAUTI) on patients and hospitals and the methods implemented in perioperative services by Abbott Northwestern Hospital (ANW), part of Allina Health, to reduce CAUTI in surgery patients.

Urinary tract infections cause 40% of hospital acquired infections. Most of these infections are due to urinary catheters. Up to 25% of hospital inpatients are catheterized. CAUTI can lengthen a patient’s hospital stay, cause pain, restrict ambulation and even lead to death. Healthcare costs related to CAUTI are increased $0.4-0.5 billion nation-wide. CAUTI identified in ICU and on med/surg units are reportable to the CDC. CAUTI reduction is an Allina-wide priority.

On any given day, a majority of Foley catheters in patient use in the hospital are inserted in surgery. The number of Foley catheters placed in the perioperative care areas (pre-op, intra-op, and PACU) was determined. Data collection identified CAUTI developing within 5 days of insertion, and these “5-day CAUTIs”/1000 Foley catheters inserted in surgical services *1000 was used to determine the rate. 27% of all CAUTIs in the hospital were identified within 5 days of insertion in surgery.

Improving Insertion Asepsis:
ANW performed an assessment of 24 RNs inserting a Foley catheter into a manikin. These RNs represented a broad range of nursing experience. 1 out of 24 attempts were observed to be aseptically inserted. These results were not unlike insertion assessment results at other hospitals nation-wide. The Minnesota Hospital Association identified establishment of criteria for catheter insertion, and use of 2- person insertion technique, having a “buddy” assist and monitor for breaks in asepsis, in their “Cut CAUTI Bundle” practices. Starting in the ICU, RN CAUTI Champions provided training to review best practices for catheter insertion, including 2- person insertion technique, with one RN using a step by step aseptic insertion checklist.

Surgery nurses were engaged as CAUTI Champions to participate in a team to collaborate with the hospital CAUTI reduction efforts. To reduce CAUTI in surgery patients, the strategy aimed at improving insertion technique to prevent breaks in asepsis, and reduce unnecessary placement of catheters. CAUTI Champions elected to teach a standard insertion technique for all Foley catheters inserted in the perioperative setting. Three standard practices for surgery were established to enhance aseptic technique:

  • Use of sterile surgical blue towels to define the sterile field.
  • A 2-person team for indwelling catheter insertion, using surg techs as the “buddy” for observing aseptic insertion and assistance to the RN.
  • Securement of the device in the OR to minimize urethral tears during positioning and transfer.

A video was filmed in the OR to engage staff in perioperative services and facilitate training the new standard practices. Mandatory return demonstration using a simulation model was required for all perioperative nurses. CAUTI data specific to surgical services insertion technique was shared with the surgery teams at staff meetings.

Perioperative Bladder Assessment Protocol
At the same time, to reduce unnecessary Foley catheter insertions, orthopedic surgeons approved a perioperative bladder assessment protocol for patients having total hip and knee joint surgery. Over 1200 total joint surgeries were performed each year with routine Foley catheter insertion. The total joint protocol aligned with CDC guidelines to use urinary catheters only as necessary, rather than routinely. Bladder scanning devices were purchased for use in surgery. Educational sessions were conducted to train nursing staff on use of bladder ultrasound scanning (BUS) devices.

  • CAUTI Champions helped to facilitate communication and promote use of the total joint surgery bladder management protocol.
  • Pre-Op RNs screened patients presenting for total joint surgery for risk factors for urinary retention and need for Foley catheter.
  • Patients mobilized in pre-op area to void prior to procedure and a post void residual BUS performed.
  • Time of last pre-operative void and the amount of post void residual documented and communicated to OR RN.
  • End of procedure, BUS assessment for urinary retention was performed by intra op RN.
  • Intermittent straight catheter algorithm followed by OR and PACU RNs.

Outcomes:
The communication between the perioperative units and patient bladder management awareness was increased. The “5-day CAUTI” rate in patients with a Foley catheter inserted in the surgery department decreased from 1.94 to 1.44 the first year after implementation of the 2-person technique. The annual goal to reduce CAUTI by 20% was achieved. The implementation of the bladder management protocol has been successful, reducing the number of Foley catheter use in patients on the orthopedic inpatient unit.

More recently, there has been an increase in CAUTI rates in patients having their Foley catheter placed in surgery. A CAUTI Clinical Action Team (CAT) was implemented to continue to investigate CAUTI cases, review charts for trends, and continue to audit practice and champion best practices. The success of the perioperative bladder assessment protocol is now well established. Surgeon groups are reviewing the protocol for use in other surgical populations.[/vc_column_text][/vc_column][vc_column width=”1/3″][vc_wp_custommenu nav_menu=”11″][/vc_column][/vc_row]

We Fight for What Matters at National AORN

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We Fight for What Matters at National AORN

Each year the AORN board of directors establishes a policy agenda based on recommendations from the National Legislative Forum. The Government Affairs team pursues these goals in legislative and regulatory arenas nationwide. Our team collaborates with health care colleagues, organizations, and decision-makers to advance patient safety and health care improvements in all operative settings, but we don’t endorse specific candidates.[/vc_column_text][vc_single_image image=”1029″ img_size=”full”][vc_column_text]

Current Policy Agenda

RN CIRCULATORS
We work to ensure every surgical patient has a dedicated perioperative registered nurse circulator for the duration of each operative and invasive procedure. Our team also actively promotes laws and regulations to ensure the supervisory presence of the perioperative RN in the perioperative setting.

WORKPLACE SAFETY INITIATIVES
Our team supports legislative and regulatory initiatives for safe perioperative work environments. Perioperative nurses deserve surgical smoke-free operating rooms, strong workplace violence protections, and safe patient handling programs focused on injury prevention.

PROFESSIONAL PRACTICE
We protect the perioperative registered nurse’s scope of practice and patient safety by engaging in legislative, regulatory, agency, and other stakeholder approaches to RN education, certification, supervision, roles, competencies, and duties.

RN FIRST ASSISTANT
We support the expanded role of the RNFA by actively working to achieve reimbursement parity for RNFAs. RNFAs work in collaboration with the entire surgical team to achieve optimal patient outcomes nationwide and yet private payer reimbursement is only guaranteed in 17 states.

PATIENT SAFETY CULTURE
We encourage legislative and regulatory efforts to establish an accountable, trusting patient safety culture in the perioperative setting, including robust whistleblower protections for healthcare providers and mandatory reporting of safety incidences, such as surgical site infections and wrong site surgery.

HEALTH SYSTEM IMPROVEMENTS
Our team promotes the role of the perioperative registered nurse in achieving the reform goals of cost containment and improved patient experiences and outcomes. Healthcare system reform efforts should recognize the contributions of the perioperative registered nurse in improving patient outcomes. AORN also promotes standardized data collection and analysis to advance improvements in patient safety and care quality.[/vc_column_text][/vc_column][vc_column width=”1/3″][vc_wp_custommenu nav_menu=”11″][/vc_column][/vc_row]

PEDIATRIC UROLOGY TUBE MANAGEMENT: YOU PUT WHAT TUBE, WHERE?

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PEDIATRIC UROLOGY TUBE MANAGEMENT:

YOU PUT WHAT TUBE, WHERE?

Presented by Katie Willihnganz-Lawson, MD at the AORN of the Twin Cities Fall Workshop November 4, 2017
Attended and Reviewed by Caroline Ness

Dr. Willihnganz-Lawson provided a great presentation reviewing the urinary tract anatomy and discussing some common GU procedures along with a review of different types of tubes and drains used in these procedures.

[/vc_column_text][vc_row_inner][vc_column_inner][vc_column_text]The urinary system structures include the kidneys, ureters, bladder and urethra. Some Urologic Surgeries related to these structures that are part of the urinary
system are:

Urethra:

  • Hypospadias
  • Posterior urethral valves
  • Urethral Stricture
  • Transurethral resection of prostate (TURP)
  • Prostatectomy

Bladder:

  • Transurethral resection of bladder tumor (TURBT)
  • Incision of ureterocele
  • Suprapubic tube
  • Vesicostomy
  • Bladder Augmentation

Ureter:

  • Ureteral stones
  • Ureteral strictures
  • Ureteral Re-implant

Kidney:

  • Pyeloplasty
  • Nephrectomy, partial
  • Kidney stones
  • Kidney tumors

Other:

  • Mitrofanoff procedure (appendicovesicostomy)
  • ACE procedures (appedicoceostomy)

The purpose of Post-Surgical Urinary Drainage tubes is to:

  • Keep natural urinary tracts open during healing process
  • Diverts urine away from healing organ and suture lines
  • Helps avoid fistula, stricture, urinoma or abscess formation.

The types of urinary catheters are and their locations:

Type:

  • Foley: a catheter with balloon
  • Council tip Foley: hole through tip to pass wire
  • Coude Foley: bend at tip to navigate urethra
  • Malecot catheter: looped end, no balloon
  • Straight catheter: no balloon, intermittent use

Location:

  • Urethra
  • Suprapubic
  • Continent channels

Foley and Straight Catheters are used to keep the surgical site drained or new urinary channel open (ie-Vesicostomy, Suprapbic tube, Continent catheter channel). Catheters are typically kept in for a minimum of 24 hours up to four weeks.

Urethral Stents are used to keep the urethra open and the bladder draining and are used in hypospadias, posterior urethral valves, and urethral stricture surgeries. Stents are typically kept in place for 7-14 days.

In reviewing the pediatric anatomy, Dr. Willignganz-Lawson noted that placing a foley catheter in a young girl may be a 2 person job in order to visualize the urethral meatus.

Common pediatric procedures:
Ureteral Reimplant is indicated when vesicoureteral reflux (VUR) causes urine to travel from the bladder up to the kidney. Depending on the grade of reflux surgical intervention is indicated when there is a high grade VUR, recurrent febrile UTI’s or failed medical management. The goal is to create a longer tunnel for ureter to prevent reflux of urine to kidneys thereby preventing pyelonephritis. There are a variety of operations: extra-vesical, intra-vesical, open vs. robotic. The tubes typically placed in this type of procedure are a double-J stent or feeding tube into the ureter (overnight to 1-3 weeks), possible penrose drain next to the bladder for 1-2 days, and a foley in urethra, usually removed post op day 1-2.

Percutaneous Nephrolithotomy (PCNL is indicated when there are large renal stones. Drains typically placed in this procedure are a stent in the ureter, foley in the urethra and nephrostomy or foley in the PCNL tract.

Pyeloplasty is indicated when there is a UPJ(ureteropelvic junction) obstruction which is a narrowing of the junction between the ureter and renal pelvis. The procedure can be performed as an open procedure or robotically. Nephrostomy tubes are a percutaneous placed kidney tube inserted by the surgeon or interventional radiologist to divert urine from the healing area for 2-3 weeks after surgery.

Bladder Augmentation
is indicated when there is poor bladder compliance or capacity. Most commonly a portion of the ileum is used as a patch. Typical drains are bladder catheters kept in for 3-4 weeks to allow anastomosis to seal, prevent leakage, and allow kidneys to drain. Irrigation of bladder catheters (urethral or suprapubic) prevents mucous plugs in the catheter.

Bladder Neck Reconstruction
is indicated when there is incontinence due to incompetent bladder neck. The tubes used in this procedure are ureteral stents, suprapubic catheters, and urethral catheters.

Continent Catheterizable Stomas-Mitrofanoff or Monti
are indicated for intermittent catheterization, difficult to catheterize through the urethra. The procedure is an appendicovesicostomy. The tubes used in this procedure are a straight catheter in newly created channel, suprapubic tube, and JP drain.

Antegrade Continence Enemas (ACE) is indicated for neurogenic bowel, and parodoxical diarrhea. Tubes used are a straight catheter or Chait tube placed for 3 weeks. A continent channel can be intermittently catheterized after healing. Chait tubes are changed every 6-12 months. Adapter is attached to the opening of the tube and enema fluids are infused through the adapter into the colon.

Some other tubes and drains in urology occasionally used in ACE or Mitrofanoff openings are Mic-KEY, Chait, Penrose and Jackson-Pratts.

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