Anda di halaman 1dari 18

Taking Steps to Control Costs in the OR



Janice Hoeksema, RN, BS, MA


Full Text




Article Outline


Cost Savings in the OR

o Disposable Versus Reusable Products
o Evaluating Implants
o Limiting Use of Custom Supplies
o Reducing Linen Use

Practice Changes
o Talcum Powder
o OR Basins
o Prep Kits
o OR Attire
o Towels


Setting Up a Product Evaluation Committee


Examination. Continuing Education Program

o Taking Steps to Control Costs in the OR


Learner Evaluation. Continuing Education Program

o Taking Steps to Control Costs in the OR






Hospitals continue to be challenged by rising expenses in an environment of moderate
reimbursements. Health care costs have increasingly come under scrutiny and, with the advent of
health care reform, will continue to be scrutinized. Perioperative nurses play a key role in
evaluating product safety, effectiveness and efficiency, environmental concerns, and cost and
how these factors affect patient care. Cost-saving opportunities that a hospital product evaluation
committee can consider include choosing less expensive but equivalent supplies, comparing the
expenses associated with disposable versus reusable products, limiting the use of custom
supplies, determining ways to reduce linen use, and changing practices to eliminate products that
are found to have little clinical value. Adopting effective product evaluation and purchasing
practices can lead to reduced costs without affecting the quality of patient care.

Key words: health care cost, health care reform, cost reduction, perioperative cost control

The need to reform health care, provide equal access, and reduce costs is currently a prominent
political topic. At a press conference on June 23, 2009, President Obama stated,
When it comes to health care, the status quo is unsustainable and unacceptable. So reform is not
a luxury. It's a necessity, and I hope the Congress will continue to make significant progress on
this issue in the weeks ahead.1(p2) if we start from the premise that the status quo is
unacceptable, then that means we're going to have to bring about some serious changes our
top priority has to be to control costs.1(p5)
Although there was considerable debate in Congress over various health care reform proposals,
there has been no controversy around the president's premise that health care is too expensive
and that the continued increase in health care costs is unsustainable under our present system.
President Obama has since signed a health care reform bill, and implementation is pending.
Regardless of how health care reform is implemented, RNs have a professional responsibility to
consider how cost affects the planning and delivery of patient care. Hospitals will continue to be
challenged by rising expenses in an environment of moderate reimbursements. On a daily basis,
perioperative nurses can significantly affect supply management practices by encouraging and
implementing strategies that promote a safe and healthy environment. Cost considerations have a
fundamental place in our professional performance. The strategies should be cost effective and
conserve resources.2(p535)
Many hospitals have effectively reduced the cost of medications through pharmacy and
therapeutic evaluation programs. The actions of these pharmacy programs have resulted in
standardization of medication purchases to specific vendors through the use of group
purchasing organizations (GPOs);
use of therapeutic equivalents (ie, generic medications);
management of medication dispensing through the use of unit doses; and
reduction of costs through practice changes (eg, review of antibiotic usage, standardization of
medication protocols).3
Pharmacy practice evaluation groups make their decisions based on research data and published
recommendations. In my experience as a consultant, however, purchasing committees have been
less successful in reducing costs related to medical-surgical supplies. It is important for nurses on
product evaluation committees to exercise the same level of professionalism as their pharmacy
colleagues when considering the selection of supplies. The pharmacy evaluation processes can

provide an effective model on which to base medical-surgical supply evaluation, selection, and
implementation activities.
Back to Article Outline

Cost Savings in the OR

Although most hospitals belong to a GPO for the purchase of supplies, ensuring that all
departments comply with purchasing from the GPO can be difficult. It is not unusual to see
supplies from non-GPO vendors used in a hospital. Most commonly, members of specialty
departments in the hospital (eg, radiology, diagnostic radiology, the OR) do their own purchasing
because their supplies are not generic to other units in the hospital, and it can be more efficient to
allow them to purchase their own supplies. Specialty department members are less likely to
adhere to GPO contracts because items purchased for these departments often are nonstock
Eliminating the practice of ordering outside the GPO has the potential to create significant cost
savings. Pharmacy practice evaluation groups, for example, have been very successful in
standardizing medication use to the least expensive medication by using generic medications.3 It
is important to evaluate common practices in the OR whenever possible to determine whether
there are less expensive alternatives.

Disposable Versus Reusable Products

A good way to look for less expensive equivalents in perioperative supplies is by comparing
disposable and reusable products. Personnel in charge of ordering supplies must perform cost
analyses periodically because the cost of reusable and disposable products changes when new
products are developed, pricing practices change, or the costs of disposal increase.
A specific opportunity for cost savings in the reusable/disposable category, for example, relates
to pulse oximetry probes. Disposable pulse oximetry probes can be a significant expense to the
hospital. They are applied to the intact skin of patients much like blood pressure cuffs, and like
blood pressure cuffs, there are some situations in which using a reusable probe makes sense. An
alert, cooperative patient who needs short-term or periodic oxygenation assessment would be a
good candidate for a reusable product. When disposables are required, using a disposable finger
probe with a reusable cable is one way to save money.
Another opportunity is the use of reusable products in laparoscopic surgery. There are outside
vendors who can manage the products to ensure that the reusable trocars are appropriately sharp.
There are also combination products that involve reusable cannulas with disposable trocars.
Basin sets are routinely used in the OR. Consideration should be given to whether use of
reusable or disposable basins would be most cost-effective.
Consideration also should be given to reprocessing disposable products if the manufacturer
supports this process and provides directions to do so and the hospital is able to provide or can

contract with a facility to do the recommended reprocessing.4 A systematic review of all

disposable products and whether they can be safely reprocessed for use or whether there are
reusable products available has the potential to create significant cost savings.

Evaluating Implants
Members of a physician-based technology committee should evaluate all implants before they
are ordered for the hospital to determine whether one type or certain types can be used that are
more cost-effective. For example, several brands of total joint prostheses may be stocked for use
in the OR without any consideration for the cost, function, and level of use. Varying types of
catheters in the cardiac catheterization laboratory are often stocked as well when perhaps one or
two types would work quite well.

Limiting Use of Custom Supplies

Another perioperative cost-saving opportunity relates to the use of custom packs. Although
custom packs have a place, supply evaluation committee members should review and analyze the
cost of each custom pack compared with the cost of using enriched standard packs. Enriched
standard packs are available that include items required for the procedure such as suction tubing,
sharps containers, x-ray sponges, laparotomy sponges, blades, specialty drapes, and specialty
gowns. It is possible to find enriched standard packs that include nearly all of the items needed
for many frequently performed procedures. There are often several options to choose from for
specific procedures as well. Hospital personnel can choose the pack option that most closely
matches the supplies they use for a procedure. Examples of these are enriched standard vaginal
delivery and arthroscopy packs (Table 1). Other enriched packs are available that have a slightly
different product configuration. Table 2 shows one option in which two standard packs can be
combined to provide most of the required items for an abdominal laparoscopy. A second option
would be to use a standard enriched laparoscopy pack.
Table 1. Examples of Enriched Standard Packs

Item description
Obstetrical pack
Placenta basin
Receiving blanket
Umbilical cord clamp
1 each
abdominal cover, back table cover, reinforced under-buttocks drape
perineal pads
vaginal packing sponge
Impervious reinforced obstetrical gown with one hand towel
X-ray detectable sponges
Impervious, reinforced gowns
Absorbent towel

Item description
20-oz bulb syringe
Standard arthroscopy pack
6-inch elastic bandage
1 each
#11 and #15 knife blades
32-oz bowls
2-oz medicine cups
2 each
7-quart containers and emesis basins
Specimen container
1 each
half sheet, extremity drape, U-drape
impervious stockinette, extra large
reinforced back table cover
reinforced Mayo stand cover
large reinforced gowns
extra large, extra long impervious specialty gown
X-ray detectable sponges
Absorbent disposable towel
Cloth towels
12-ft nonconductive suction tubing
Table 2. Examples of Laparotomy Packs



Option 1: use of 2 standard packs

Standard laparotomy pack
Standard basin set
Reinforced back table cover
Emesis basin
Reinforced laparotomy drape
2 each
32-oz and 7-quart basins
Reinforced Mayo stand cover
Cautery tip cleaner
Impervious, reinforced gown with towel 2
Medicine cups
Scrub gown with towel in outer wrap
Specimen cup with screw-top lid
Needle counter
Suture bag
Graduated 1,000-mL pitcher
Adhesive drape towels
Laparotomy sponges 18 18
X-ray detectable 4 4 sponges
Bulb syringe
12-ft suction tubing
Option 2: use of 1 enriched standard major abdominal pack
Large scrub gown with cloth towel 1 Fabric reinforced large gown
Reinforced Mayo stand cover
1 Laparotomy drape
Reinforced back table cover
4 Adhesive drape towels
Cloth towels
2 Each #10, #15, #20 knife blades

Option 1: use of 2 standard packs

Standard laparotomy pack
Standard basin set
1 Reinforced back table cover
Emesis basin
10 Laparotomy sponges
10 X-ray detectable 4 4 sponges
1 Suture bag
1 Mayo tray
1 Needle counter
1 Cautery tip cleaner
1 Yankauer suction tip
1 12-ft nonconductive suction tubing
1 60-mL Asepto syringe
1 Prep tray kit
With these options, hospital personnel should be able to find a configuration that works well for
them without resorting to using a custom pack. The few additional items that may be included in
a custom pack are often priced higher than the same items when purchased separately. It would
be more cost-effective, therefore, to have staff members add these items to the set instead of
using a custom pack. Procedures such as vaginal delivery, tonsillectomy, myringotomy, breast
biopsy, hernia repair, arthroscopy, and major abdominal procedures should not require a custom
pack. Use of custom prep kits instead of standard prep kits results in significant unnecessary
expense to the hospital as well.

Reducing Linen Use

Perioperative personnel in the past have used bath blankets and pillows to position patients in the
OR when other less expensive, patient-safe alternatives have been available. In the interest of
patient safety, perioperative personnel should not substitute bedding or linen for positioning
aides. These substitutions are not cost-effective and cannot guarantee the level of protection from
pressure ulcer development that commercially available positioning aids can.
In an effort to reduce costs, it is important to review linen use in the hospital. Figures vary from
use as high as 22 lb per adjusted patient day (ie, the number of occupied beds divided by the
pounds of linen used per day) to as little as 10 lb per adjusted patient day.5 Geography does affect
linen use. Hospitals in hot climates tend to use less linen than hospitals in very cold climates;
however, there are still many other opportunities to consider to reduce linen use. For example, to
reduce the incidence of clean, unused linen ending up in the dirty linen hamper, linen should not
be brought into the OR unless it is needed. For the same reason, linen should not be brought into
the room of a patient who is expected to be discharged. Enforcement of a rational linen policy is
important for cost reduction. Bed linen standards should be established for the OR patient's bed
(ie, what the normal linen requirements are for an OR bed and any exceptions to those
requirements). Extra sheets and linen should not be placed on the bed when a therapeutic
mattress is in use.
From a patient comfort standpoint and as a cost-reduction strategy, gowns with sufficient front
and back coverage should be selected to eliminate the need to use a second gown as a cover robe.
Use of gowns with adequate coverage can also reduce, if not eliminate, the use of bath blankets
to cover patient chairs in the outpatient postoperative area.

Most hospital's linen vendors can supply, free of charge, a review of linen use report.
Perioperative personnel should analyze this report to identify where opportunities exist for
reduced linen use. This review can be undertaken by RNs who are also able to help the hospital
determine reasonable targets for reducing linen use based on the hospital's geography and other
Back to Article Outline

Practice Changes
All products used in the hospital should be assessed for the clinical value they provide to patients
and whether there is evidence to support their use. If there is no added value or clinical reason to
justify their use, they should be eliminated.

Talcum Powder
Talcum powder, for example, has been eliminated from use in the newborn nursery. In the past,
it was common to use talcum powder to protect a baby's skin and absorb excess moisture.
Physicians no longer recommend this, however. Inhaled talcum powder can irritate a baby's
lungs.6 Unfortunately, talcum powder is still being used on adult patients, especially those who
are elderly, obese, or confined to bed. Talcum powder poses a similar respiratory risk to those
patients without providing any clinical benefit. Nurses specializing in skin care can offer
individual patient assessment and better solutions to managing the skin concerns of these

OR Basins
Basins that are used during surgical or invasive procedures to organize nonliquids should be
considered for elimination. Only basins needed for liquids should be used. This could
significantly reduce the number of basins purchased and/or reprocessed.

Prep Kits
The long-standing practice of shaving surgical or invasive procedure sites has been eliminated
because of its connection to surgical site infections (SSIs). The Centers for Disease Control and
Prevention in its Guidelines for the prevention of surgical site infection states,
Preoperative shaving of the surgical site the night before an operation is associated with a
significantly higher SSI risk than either the use of depilatory agents or no hair removal Other
studies showed that preoperative hair removal by any means was associated with increased SSI
rates and suggested that no hair be removed.7(p257)
Thus, eliminating preoperative shave kits and razors for surgical preps is an excellent cost-saving

OR Attire
Many items of OR clothing have undergone scrutiny in regard to their use in infection control.
For example, AORN states that the use of cover apparel should be determined by the individual
practice setting. The value of cover apparel worn in the institution is unsubstantiated. The use of
cover apparel has been found to have little or no affect on reducing contamination.8(p68) The
practice of wearing a cover gown outside the OR should be evaluated and eliminated if this will
reduce costs and does not affect patient safety.
Perioperative Product Selection Guidelines1

Evaluating products for use in the perioperative setting requires input from all stakeholders and
is best handled by a committee chosen for this purpose. Committee members should be
representative of personnel from the surgical services, anesthesia, nursing, and central processing
departments. Committee members from outside the perioperative department may include, but
are not limited to, personnel from the infection control, administration, pharmacy, biomedical
engineering, radiology, laboratory, and risk management departments.
Committee members should evaluate all products proposed for use in the OR for safety, function,
and cost-effectiveness. Members of the team may be required to participate in or initiate clinical
evaluation of proposed products or devices. When evaluating products or devices, committee
members must assess ease of use, processing, and sterilization. It is important to ensure that
proposed products are compatible with the ability of facility personnel to comply with product or
device requirements for use or processing. Proposed products should be compatible with existing
equipment and supplies, have a positive effect on patient care, and be under regulatory control.
Products selected for use should be evaluated for liability issues. Clinical evaluations of certain
products may be needed to ascertain their appropriateness for use in the individual facility. To
facilitate this process, management personnel should write appropriate policies and procedures,
review them at specified intervals, and make them available to staff members and members of
the committee.
Eliminating the traditional skull-type surgeon caps is an effective cost-reduction strategy. These
caps usually do not adequately cover the hair or prevent shedding of hair or skin cells,8 the sole
reason for wearing a head covering, and they have a higher cost. Standardizing hair covers to
bouffant caps, or hoods for staff members with facial hair, provides better hair coverage, is more
effective for infection prevention, and reduces cost.

In the OR, woven cotton towels are commonly used during surgical procedures. This type of
towel has a very loose weave; it readily absorbs liquids and wicks moisture. It is not an effective
barrier, however, and should not be used for patient draping in surgical or invasive procedures.
There are nonwoven, synthetic towels that provide a superior barrier at a lower cost.9, 10, 11 It

generally is less expensive to use a nonwoven, heavy-duty back table cover than to use cotton
towels for padding on the back table. A nurse practice committee should review the use of these
towels and set a goal to eliminate them from the practice setting.
Back to Article Outline

Setting Up a Product Evaluation Committee

These are just a few examples of the cost-savings opportunities that are available to hospitals.
Nursing practice committees should systematically review practices and the products they use in
the same manner as pharmacy practice evaluation groups. Department members who have served
in leadership positions on committees that have conducted similar reviews would be good
resources to provide information about setting up a product evaluation committee in the OR.
They will have addressed political issues specific to a given hospital and can provide guidance
on what worked and what did not. AORN's Recommended practices for product selection in the
perioperative practice setting also provides useful guidance in setting up a committee and
directions for its function.12 An initial step for selecting items for study is to obtain a list from the
purchasing department or the business office of all the products used in the OR, sorted in
descending order of annual cost. These lists can be used to prioritize evaluations of products used
in the OR for safety, necessity, and cost-effectiveness.
Back to Article Outline

Significant savings are available to most hospitals when ordering practices and patient care
practices are evaluated and amended. It is in the best interest of employees and patients that these
reviews be conducted on a regular basis. Depending on the size of the hospital, these savings
could reach millions of dollars. When done carefully and with patient care as a driving focus,
scarce health care money that is saved can be better spent.
Back to Article Outline

Examination. Continuing Education Program

Taking Steps to Control Costs in the OR
To educate perioperative nurses about perioperative cost-control measures.
1.Discuss the role of the perioperative nurse in OR cost containment.

2.Identify practices that increase OR costs.

3.Describe methods to reduce OR costs.
The Examination and Learner Evaluation are printed here for your convenience. To
receive continuing education credit, you must complete the Examination and Learner
Evaluation online at

1.Perioperative nurses can significantly affect supply management by implementing strategies

1.are cost-effective.
2.are tailored to individual physician requests.
3.provide a safe environment.
4.conserve resources. a. 1 and 2 b. 3 and 4 c. 1, 3, and 4 d. 1, 2, 3, and 4

2.Supplies from vendors outside of the group purchasing organization are often used in the
hospital because
1.members of specialty departments may do their own purchasing. used in specialty departments are not generic to other units in the hospital.
3.ordering supplies outside of the group purchasing organization can result in significant cost
4.some of the items used specialty departments are nonstock items. a. 1 and 3 b. 2 and 4 c. 1, 2,
and 4 d. 1, 2, 3, and 4

3.When evaluating the cost of using reusable versus disposable products, personnel in charge of
ordering supplies must perform periodic cost analyses because
1.the costs of products change as new products are developed.
2.pricing practices change.
3.the cost of disposal increases.

4.personnel compliance with usage decreases. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4

4.Items included in a custom pack are often priced higher than the same items when purchased
separately. a. true b. false
5.Using bath blankets and pillows to position patients in the OR is a safe and inexpensive
alternative to using commercially available positioning aides. a. true b. false
6.To reduce costs associated with linen use
1.only disposable linen should be used.
2.linen should be assigned to each patient.
3.linen should not be brought into the OR unless it is needed.
4.gowns with sufficient front and back coverage should be used to eliminate the use of a second
gown as a cover gown.
5.personnel should analyze the review of linen use report available from the hospital's linen
vendor. a. 1, 2, and 3 b. 3, 4, and 5 c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5

7.Eliminating preoperative shave kits and razors for surgical preps is an excellent cost-saving
tactic. a. true b. false
8.The wearing of _________________________ is not supported by evidence and should be
eliminated if it reduces costs and does not affect care.
a.disposable hair covers
b.long-sleeved warm-up jackets
c.shoe covers that ground electricity
d.cover gowns outside the OR

9.Eliminating traditional skull-type surgeon caps is an effective cost-reduction strategy because

the caps usually do not cover the hair adequately and have a higher cost than other types of head
covers. a. true b. false
10.Members of a product evaluation committee should evaluate products for

4.ease of use. a. 1 and 2 b. 3 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4

The behavioral objectives and examination for this program were prepared by Helen Starbuck
Pashley, MA, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC,
director, Center for Perioperative Education. Ms Pashley and Ms Bakewell have no declared
affiliations that could be perceived as potential conflicts of interest in publishing this article.
Back to Article Outline

Learner Evaluation. Continuing Education Program

Taking Steps to Control Costs in the OR
This evaluation is used to determine the extent to which this continuing education program met
your learning needs. Rate the items as described below.
To what extent were the following objectives of this continuing education program achieved?
1.Discuss the role of the perioperative nurse in OR cost containment. Low 1. 2. 3. 4. 5. High
2.Identify practices that increase OR costs. Low 1. 2. 3. 4. 5. High
3.Describe methods to reduce OR costs. Low 1. 2. 3. 4. 5. High

4.To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5.
5.To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
6.Will you be able to use the information from this article in your work setting? 1. Yes 2. No
7.Will you change your practice as a result of reading this article? (If yes, answer question #7A.
If no, answer question #7B.)

7A.How will you change your practice? (Select all that apply)
1.I will provide education to my team regarding why change is needed.
2.I will work with management to change/implement a policy and procedure.
3.I will plan an informational meeting with physicians to seek their input and acceptance of the
need for change.
4.I will implement change and evaluate the effect of the change at regular intervals until the
change is incorporated as best practice.
5.Other: _____________________________

7B.If you will not change your practice as a result of reading this article, why? (Select all that
1.The content of the article is not relevant to my practice.
2.I do not have enough time to teach others about the purpose of the needed change.
3.I do not have management support to make a change.
4.Other: _____________________________

8.Our accrediting body requires that we verify the time you needed to complete the 1.6
continuing education contact hour (96-minute) program: ___________
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing
education requirements.
AORN is accredited as a provider of continuing nursing education by the American Nurses
Credentialing Center's Commission on Accreditation.
AORN recognizes these activities as continuing education for registered nurses. This recognition
does not imply that AORN or the American Nurses Credentialing Center approves or endorses
products mentioned in the activity.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number
CEP 13019. Check with your state board of nursing for acceptance of this activity for
Event: #10506; Session: #4053 Fee: Members $8, Nonmembers $16

The deadline for this program is December 31, 2013.

A score of 70% correct on the examination is required for credit. Participants receive feedback
on incorrect answers. Each applicant who successfully completes this program can immediately
print a certificate of completion.
Back to Article Outline

1. President Obama's press briefing. The New York Times. June 23,
pagewanted=1&_r=1Accessed June 28, 2010
o View In Article

2. AORN guidance statement: Environmental responsibility. In: Perioperative

Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 533540
o View In Article

3. American Society of Health-System Pharmacists. ASHP guidelines on medication cost

management strategies for hospitals and health systems. Am J Health-Syst Pharm.
August 2, 2010
o View In Article

4. AORN guidance statement: Reuse of single-use devices. In: Perioperative Standards and
Recommended Practices. Denver, CO: AORN, Inc:649-655.
o View In Article

5. Phillips GP. Linen use in an era of managed care. Health Facilities Manage.
December 1,
NEAccessed July 28, 2010
o View In Article

6. Diaper rash: lifestyle and home remedies. June 23,

2009; June 29, 2010
o View In Article

7. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention
of surgical site infection, 1999 (Hospital Infection Control Practices Advisory
Committee). Infect Control Hosp Epidemiol. 1999;20(4):250
278 June 29, 2010
o View In Article
o CrossRef

8. Recommended practices for surgical attire. In: Perioperative Standards and

Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 6773
o View In Article

9. Wubbe E. Disposables on the rise in the medical market. Nonwovens Industry.

November 2001; June 28, 2010
o View In Article

10. Belkin NL. The new barrier standardwhose interests does it serve?. AORN J.
o View In Article
o Full Text
o Full-Text PDF (435 KB)
o CrossRef

11. US Patent 5409761Breathable non-woven composite barrier fabric and

fabrication process. PatentStorm. July 2,
1993; August 2, 2010
o View In Article

12. Recommended practices for product selection in the perioperative practice setting.
In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;
2010;p. 189192
o View In Article

Janice Hoeksema, RN, BS, MA, was the director of the Perioperative Department at Spectrum
Bodgett Memorial Medical Center, Grand Rapids, MI, and worked as a sales representative and a
senior consultant in cost reduction/supply chain management for Cardinal Health, Dublin, OH,

before retiring. Ms Hoeksema has no declared affiliation that could be perceived as posing a
potential conflict of interest in the publication of this article.

1 Recommended practices for product selection in perioperative practice settings. In:

Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;

indicates that continuing education contact hours are available for this activity. Earn the
contact hours by reading this article, reviewing the purpose/goal and objectives, and completing
the online Examination and Learner Evaluation at The contact hours
for this article expire December 31, 2013.
PII: S0001-2092(10)01056-2
2010 AORN, Inc. Published by Elsevier Inc. All rights reserved.