Critical Analysis of Surgical Patient Care: A Comprehensive Report

This report provides a critical analysis of surgical patient care, focusing on the role of a surgical care practitioner in the perioperative setting. It examines contemporary issues and challenges, emphasizing the importance of effective communication with patients and the surgical team. The report synthesizes theory and practice, addressing learning from incidents and implementing solutions to minimize risks. It critically evaluates communication methods, health and safety practices, and infection control across the perioperative environment. Furthermore, the report explores communication methods during patient admission and transfer, the evaluation of technical language and skills required when anaesthetising patients, and the reflection upon the patient's medical history to select the most appropriate anaesthetic technique. The report also considers the duty of care, professional boundaries, and the contributions of scrub practitioners and circulating personnel to safer surgery. The report is based on a case study of a virtual patient, Mr. Oliver Orange, and offers valuable insights into the multifaceted aspects of surgical patient care.

Surgical Patient

TABLE OF CONTENTS
INTRODUCTION...........................................................................................................................1
MAIN BODY..................................................................................................................................1
1.Critically appraise my own role in relation to the care of the surgical patient.........................1
2. Critically examine contemporary issues and challenges in surgical care................................2
3. Synthesising theory and practice in relation to learning from incidents and implementing
solutions to minimise the likelihood of them reoccurring...........................................................2
4. To critically evaluate communication methods in the peri -operative setting.........................3
5. To reflect upon the impact of effective communication with patients and members of the
peri operative team......................................................................................................................3
6. To critically evaluate health and safety practices in the peri operative settings......................4
7. To reflect upon the impact of infection control practice across the peri operative
environment and other hospital departments...............................................................................4
8. To critically evaluate communication methods when receiving, admitting and transferring
patients.........................................................................................................................................5
9. reflect upon other effective forms of communication with patients........................................5
10. Evaluation of technical language and skills required when anaesthetising patients..............6
11. To reflect upon the patient's medical history and select the most appropriate anaesthetic
technique......................................................................................................................................6
12. to critically evaluate how a duty of care is met in practice...................................................7
13 reflect upon the practitioner's professional boundaries and link them to a duty of care........8
14. to critically evaluate how the scrub practitioner contributes to safer surgery.......................8
15. to reflect upon the role of the circulating person and how their actions lessen the risks in
the surgical swab counts..............................................................................................................9
CONCLUSION................................................................................................................................9
REFERENCES..............................................................................................................................11

INTRODUCTION
Nursing being a vital part of treatment plays a considerate role in taking care of the
surgical patients who are required to be treated in succession of several caring measures. These
are mostly related to another potent consideration of perioperative measures in the field of
nursing with a special consent of surgical patients (von Dossow and Zwissler, 2016).
Peroperative measures primarily involves the method of evaluation followed by management and
lastly carrying out pertinent outpatient processes. It is normally done before conducting any
elective surgical procedures and is usually done by the non-surgical consultants like
cardiologists, internists and pulnomologists, etc. This type of consulting mostly assists in the
management of any prior medical issue of the client such as diabetes, etc., that may in turn
impact upon the existing health related problem of the client. It also supports in the treatment of
peri and post-operative complications that may arise in the form of any other infectious disease
or cardiac and pulmonary related issues (Young and et.al., 2016). The below report has
discoursed upon a similar consideration of surgical patient to be treated with the help of
perioperative measures and is based upon a given case study of a virtual patient named Mr Oliver
Orange and is 56 years old.
MAIN BODY
1.Critically appraise my own role in relation to the care of the surgical patient
I am hereby playing the role of a surgical care practioner who will be mainly responsible
for taking care of those patients who are either operated or are in need of some surgical
procedure. This in turn necessitates me to perform the perioperative practices that will in turn
involve its 3-step process namely evaluation, management and outpatient procedures (Buckley
and et.al., 2016). It is with a special consent of the conferred case scenario of Mr Oliver Orange
who is 56 years old and has been recently admitted to the hospital followed by a workplace
accident. I have met him in a perioperative setting that necessitated me to go through the three
phases of scaphoid surgery for which he was diagnosed (Macht and et.al., 2016).
This is basically on considering the leading agenda of perioperative care that intends to
provision improved condition to the patients before, during and after the operation. With a
similar reference to it, the three-stage perioperative practice includes preoperative, intraoperative
and postoperative services where each of these processes are with a distinct consent (Garrett,
1

2016). I am hereby required to go through the three mains steps of evaluation in terms of going
through his past medical history, management for looking into a well considerate course of
surgery to avoid any possible chances of obstacle and outpatient (Scott and et.al., 2017). This is
basically to verify a sustained perioperative process for avoiding any probable complications
after the surgery to ensure a successful surgical treatment of Mr Orange.
2. Critically examine contemporary issues and challenges in surgical care
Attempting to accompany a surgery with several set of responsibilities is itself referred to
be a major challenge for a surgical care practioner who is required to look into all relative
measures of the surgical procedure to avoid any atrocious fallouts with the wellbeing of client
(Chan and et.al., 2017). It is where surgical nursing itself exists with both physical and emotional
challenges for the nurse. This is with a similar reference to the given case of Mr Orange where
the scaphoid surgery for the treatment of his fracture is referred to be physically demanding in
nature and I am hereby required to be aware of the time period I need to spend in the operative
room. On considering the emotional challenges I may face while treating Mr Orange, I am afraid
about any distressing results that could occur in case the surgery goes wrong. It is thereby on the
basis of the above two challenges, it can be said that patient safety is one of the most concerning
issue where it is mostly due to general guidelines with no precise measures to handle a specific
set of patients (Isenman, Michaels and Fisher, 2016). Also, communication plays a vital role in
health care settings where gap in communication leads to no transmission of information across
the surgical care pathway.
3. Synthesising theory and practice in relation to learning from incidents and implementing
solutions to minimise the likelihood of them reoccurring
This is on scrutinizing the above relative facts to further create a theory and practice of
improvement in it, I have hereby learned to behave in a peaceful manner to avoid any sort of
physical and mental challenges to perform the act of surgical care (Bruno and et.al., 2017). For
which, I will also consider following an integral process of communication with a foremost
consideration of listening and attending any queries made by the patient and his or her relatives.
A proper communication procedure is apparent to reduce the chances of mishaps and will
minimize the probabilities of risk.
2

4. To critically evaluate communication methods in the peri -operative setting
Communication plays an important role in a peri-operative setting that in turn makes a
huge contribution in the undertaken surgery of the patient. A healthcare setting is comprised with
enormous number of individuals such as patients, their family members and relatives along with
the professional colleagues (Larochelle and et.al., 2016). It is therefore intended to be a
significant prospect for the practioners to communicate in an effective manner as an essential
medical skill. This is also referred to be a principal requirement for provisioning an intensive
healing facility and a key to perform respectable medicinal practices. The current section has
hereby referred to evaluate the communication methods that are likely to be used in the
perioperative settings. This involves a foremost method of listening and attending the patients
like Mr Orange and his family members or relative to address their concerns. On evaluating the
practice of listening, it is always referred to initiate a respectful interaction of the practioner with
that to the client and his or her relatives. This is for instance to refer to the case of Mr Orange, if
I will prioritize listening to the issues of Mr Orange, I will be able to generate better ways and
ideas to assist him at the rime of treatment (Palant and et.al., 2017). This will in turn fulfil both
my professional responsibilities towards him by together fulfilling his personal desires.
5. To reflect upon the impact of effective communication with patients and members of the peri
operative team
An effective communication is referred to be a key top get success in surgical care where
it directly results in enhancing the provisioning of services to the patients like Mr Orange.
Despite of several communication methods like verbal, non-verbal, questioning and written,
communication in a health care setting, it is made effective with a primary use of the listening
measure that leads the person to make an effective selection of the treatment to be given to the
patient going through a traumatic disorder (Clayton and et.al., 2016). Apart from this, listening
and paying attention also leads to an effective perioperative procedure that in turn assist the
surgeons and surgical practioners to provide a likely treatment to the patient with less or almost
no pessimistic consequences. This will also lead to an accurate diagnosis of the patient to further
provisioning a correct treatment which is harmless for the patient and also leads to a greater level
of satisfaction for both the patient and the team of experts provisioning the services.
3

6. To critically evaluate health and safety practices in the peri operative settings
This is to evaluate the health and safety practices in the perioperative settings by
scrutinizing the efficacy of the applied practices. This mainly involves three leading measures in
accordance to The Universal Protocol, WHO surgical safety checklist and Patient involvement.
On evaluating these methods, it has been found that The Universal protocol is much effective in
terms of verifying the pre-operative practices by the surgical practioner like me and include
preprocedural process of verification followed by the marking of operative site and carrying out
a time out before the process (Handzo, 2012). Another undertaken method defines an imperial
use of Surgical Safety Checklist which is yet another beneficial tool for promoting the safety of a
client. On evaluating this measure, it has been found that such verification process largely assists
in reducing any possible chances of risks and errors by the surgeons in the operative room.
Lastly, there existed another significant measure of involving patients that includes an official
enlistment of patient for preventing any possible errors in the operative area. On evaluating this
measure, it has been found that it is a slight challenging task that requires the surgeon to put his
personal efforts by calming the patient at the time of preoperative assessment procedure.
7. To reflect upon the impact of infection control practice across the peri operative environment
and other hospital departments
This is to reflect upon the undertaken practices of infection control across the
perioperative environment where during this course of time where I was supposed to take care of
Mr Orange, I have strictly followed the below mentioned measures for controlling infection-
 Hand hygiene- This indicated a foremost way for minimizing the risk of spreading
infection where decontamination of hands is evident to defend both the service user
and the provider (Beam, Keating and Razonable, 2016). I have thereby considered
washing my hands every time I met Mr Orange and left her room for the elimination
of microorganism that can be easily transferred to any healthy person by together
harming any patient like Mr Orange to a great extent.
 Aseptic technique- This was reflected to be yet another effective measure for the
prevention of any infectious ailment to the patients like Mr Orange (Mueller and
et.al., 2016). This duly necessitated me to sterilize and disinfect the medical devices
used for the purpose of diagnosis. It together indicated a dual process has been done
before and after detecting the clients to prevent the spread of any infection.
4

8. To critically evaluate communication methods when receiving, admitting and transferring
patients
Communication being an important agenda usually involves oral and written methods at
the time of receiving, admitting and transferring patients. Firstly, an interaction takes place
among the referring and the receiving team to communicate about the condition of the patient,
examination, plans for treatment, measures and timings for the transfer, etc., (Atkinson and et.al.,
2017). It is with a special concern of confirm the acceptance of entrance to the unit receiving the
patient. On evaluating the same, a slight discrepancy has been found over here where it is
important to provide any updated set of information about any sort of development in patient’s
condition to further proceed in an accordant manner.
9. reflect upon other effective forms of communication with patients
As a surgical practitioner, I have analysed that it is very essential to have effective
communication with the patients so that their problems could be easily understood and necessary
actions could be taken up. There are various forms of communication that could be used for
interaction with patients. Some of them are discussed below: Rapport: When there is effective communication between patients and doctors, it
becomes easy to provide cafe to them. It could be enhanced by calling them with their
names, having proper eye contact while talking to them etc, could build up healthy
relations among them (Janis, 2016). Explain: Patients could be asked with variety of questions that could motivate them to
indulge themselves more into treatment procedures. They could be asked about their
routines, habits and desires etc., which helps in getting more frank with the working
team. Show: It is always appreciable when someone collaboratively works with one another as
team. Doctors and hospital service in-charge should participate in helping others rather
than instructing them to accomplish following tasks.
 Practice: it is an old saying that practise makes a man perfect. It is actually true in every
aspect. When physicians are provided with trainings on how to deal with service users, it
becomes easy for both of them to cooperate one another.
5

10. Evaluation of technical language and skills required when anaesthetising patients
Language and skills used for communicating with patients while inducing anaesthesia
plays a major role in the entire treatment procedure. Trained professionals are generally
preferring conscious communication only. It is in verbal form and generally involves logic
behind everything (Piazza, Kalesan and Kappetein, 2013). Patient should be provided with all the
necessary information regarding anaesthesia which may include its type, method to be used into
the process and its effect in the body. It is also essential to ensure that there should not be side
effects of it on the body.
Nowadays case of surgical errors has come into existence over the past few years. The
reason behind this could be unresponsive behaviour of doctors and lack of patient's involvement
in the treatment. Thus, it becomes very important that service user should be well aware about
the medications that have been provided to them. Professionals should be well trained because if
misconduct occurs then ultimately client have to bear the damages.
While giving anaesthesia, certain instructions could be given to the users such as lie still,
raise your arm, release your body, etc. Patients should be asked to follow all the instructions
carefully. In the subconscious state, sometimes people are not able to hear and follow the
instructions carefully which may be dangerous to them (Nicholson, Lowe and Smith, 2014). In
such cases, they could be asked to remain firm and it becomes the responsibility of the hospital
authorities and involved doctors to ensure that the whole procedure gets completed in a
systematic manner without facing any challenges. Patients should calmed by providing support
and care that would be helpful in building confidence in them.
11. To reflect upon the patient's medical history and select the most appropriate anaesthetic
technique
As per the given case, patient has a medical history of hypertension and angina. Mr.
Orange is taking medications for it. Patients suffering from hypertension are generally
asymptomatic. It is a common medical issue that is faced by many individuals across the world.
It has been found that if blood pressure is greater than 160/100, then it presents case of
hypertension (Cecconi, Corredor and Rhodes, 2013). While working as surgical Practitioner, to
deal with the given situation I would be providing anaesthesia and certain questions would be
asked to them so that patients exact mental condition could be analysed.
6

Before providing anaesthesia, patient should be asked about their medical history
regarding illness which may include heart issues, kidney failure etc. It is important to find out the
extent of hypertension as well because according to that only anaesthesia could be induced into
body else the whole body would have side effects leading to issues like state of being in comma,
mental issues and many more.
Patients like Mr. Orange require treatments on urgent basis. Some of the techniques that
could be utilised are discussed below:
 General Anaesthesia: it is basically utilized so that unconscious state could be created.
For this, variety of medications are available that could be used such as pain killers,
aesthetic vapours etc.
 Monitored Anaesthesia care: It is generally used by the surgeons in case when they are
required to perform surgeries and close observation is required to carry out for
identifying problems (Ghignone, Van Leeuwen and Ugolini, 2016). Patient's cooperation
is much needed in such cases.
12. to critically evaluate how a duty of care is met in practice
In health care premises, it is very essential to identify potential factors that could affect
implementation of services and support in the organization. Thus, basic function for the
authorities is to identify extent to which risk can cause harm and its probabilities that it would
occur again in the near future. If chance of occurrences for specific issue is more, then huge
attention is required to be given to them considering its seriousness. According to the
Arulkumaran, Corredor and Cecconi, (2014), breaching of duty of care could arise several issues.
Relationship between a doctor and patient is needed to be healthy. When there is good
communication between them, it becomes easy to handle health issues (Arulkumaran, Corredor
and Cecconi, 2014).
When there is involvement of patients in the entire treatment procedure, then things
become easy to identify and provide medications accordingly. Medical errors have come into
existence over the few years which is required to be dealt off properly because medical errors
could raise issues. Thus, doctors should be provided with trainings so that they could have
enough knowledge about providing services to the clients. They should be also taught about how
to use updated equipments because technology advancement has given rise to many new
treatment opportunities and has increased life expectancy as well (Martin, Jacob and Kurz,
7

2013). It is the responsibility of authorities only that patients are provided with all the safety
measures along with quality medications without being biased on any grounds.
13 reflect upon the practitioner's professional boundaries and link them to a duty of care
While working within health care organizations, there are certain limitations that comes
across in working procedures. It is always appreciable to build healthy relations at workplace
among employees and patients. But it is also necessary that it should be build in such a way that
basic requirements of the service users are met. Nurses and doctors are not allowed to have
personal relationships with the patients while serving their duty of care (Okabayashi, 2014).
Socialization should be in such a way that set boundaries by the hospital authorities should not
get crossed.
Professional boundaries should not get violated and if it is found then responsible person
should be reported. Customers information and details are available to the healthcare
organizations and it becomes very essential to maintain confidentiality because nobody has rights
to breach someone's privacy. It is also needed to ensure that quality services are being provided
to all the users without being biased and discriminated on any basis.
One should also ensure that people should not be engaged into making personal benefits
by charging high fees and inappropriate financial transactions (Umpierrez, 2013). It is also
needed to ensure that transparent working practices is ensured within the organization so that
nobody could engage themselves into misconduct behaviours at workplace.
14. to critically evaluate how the scrub practitioner contributes to safer surgery
In healthcare organisation, the role of scrub practitioners could be defined as providing
assistance to the surgeons in the surgical process so that patient's care in an appropriate manner
could be ensured. It is thus required that staff involved into these practices gets high
competencies.
Scrub Practitioners are basically engaged into providing care to the customers in the
procedure of operations (Gerrits, 2013). For this, they are required to carry out checks on needle,
instruments, equipments that would be used during surgery are of optimum quality. Needles are
needed to be new every time and it should be ensured that pre-used injections should not be
utilized again. As per the surgeon's specifications, specimens are needed to be handled with care
properly. They are also engaged into safer disposals of all the sharps according to the hospital’s
policies.
8

Scrub practitioners looks upon proper management of equipments and clinical wastes get
disposed properly. Patients dignity and privacy should be maintained (Harris and et.al., 2015).
They hold private details of the clients which is needed to be maintained confidential by the
hospital authorities only. Practitioners could contribute into this segment.
15. to reflect upon the role of the circulating person and how their actions lessen the risks in the
surgical swab counts
Circulating person also has associated responsibilities which is required to be performed
by them. They are needed to check proper functioning of all the machineries and equipments in
the healthcare organisations. They are needed to investigate that operation theatre are clean after
surgeries. Scrub practitioners are assisted by circulating person in setting up operation theatre so
that all the necessary requirements could be made available to them (Gili-Miner, 2014). On the
Operation table, they are needed to place clean bed-sheet. Thus, they are engaged into
maintaining nursing care and act as support system in the surgical team. They are not necessarily
required to be present in the room during operation, thus they could move outside as well and
collect information.
They are also engaged into observing possible errors that may occur during the surgery
which may include use of injections that have been previously used, providing anaesthesia to the
patients, etc. (Laflamme and et.al., 2015). In the given case, Mr. Orange is a patient which could
be assisted by circulating nurse in his treatment to ensure he does not get aggressive and if the
situation arise, necessary actions could be taken up to control him. They help patients from
getting harmed by others as well as also look upon them that they do not cause damage to their
health.
CONCLUSION
From the above report, it can be concluded that in health care organisations, it is very
essential for all the professionals to be provided with proper trainings so that they could be able
to handle situation and patients properly. Scrub practitioners and circulating persons have
associated job responsibilities such as assisting surgeons in the operation theatre, observing them
so that possible errors could be controlled, etc. Effective communication with patients helps in
building good relations with the patients and is also beneficial in identification of problems from
which they are suffering.
9

REFERENCES
Books and Journals
Arulkumaran, N., Corredor, C. and Cecconi, M., 2014. Cardiac complications associated with
goal-directed therapy in high-risk surgical patients: a meta-analysis. British journal of
anaesthesia. 112(4). pp.648-659.
Atkinson, R. A and et.al., 2017. Management and cost of surgical site infection in patients
undergoing surgery for spinal metastasis. Journal of Hospital Infection. 95(2). pp.148-
153.
Beam, E., Keating, M.R. and Razonable, R.R., 2016. A survey of infection prevention and
control practices among hematopoietic stem cell transplant centers. infection control &
hospital epidemiology. 37(3). pp.348-351.
Bruno, E and et.al., 2017. An Evaluation of Preparedness, Delivery and Impact of Surgical and
Anesthesia Care in Madagascar: A Framework for a National Surgical Plan. World
journal of surgery. 41(5). pp.1218-1224.
Buckley, L. F and et.al., 2016. Invited Commentary: Initial Experience with Direct Oral
Anticoagulants in the Perioperative Setting. Current Emergency and Hospital Medicine
Reports.4(2). pp.88-92.
Cecconi, M., Corredor, C. and Rhodes, A., 2013. Clinical review: Goal-directed therapy-what is
the evidence in surgical patients? The effect on different risk groups. Critical care. 17(2).
p.209.
Chan, B. C. Y. and et.al., 2017. Infection control practices in Mohs micrographic surgery: a UK
national survey. British Journal of Dermatology.
Clayton, J and et.al., 2016. Perioperative nurses’ experiences of communication in a
multicultural operating theatre: A qualitative study. International journal of nursing
studies.54. pp.7-15.
Garrett, J.H., 2016. Effective perioperative communication to enhance patient care. AORN
journal.104(2). pp.111-120.
Gerrits, J. H., 2013. Polymorphic mononuclear neutrophils CD64 index for diagnosis of sepsis in
postoperative surgical patients and critically ill patients. Clinical chemistry and
laboratory medicine. 51(4). pp.897-905.
10

Ghignone, F., Van Leeuwen, B. L. and Ugolini, G., 2016. The assessment and management of
older cancer patients: A SIOG surgical task force survey on surgeons' attitudes. European
Journal of Surgical Oncology (EJSO). 42(2). pp.297-302.
Gili-Miner, M., 2014. Alcohol use disorders among surgical patients: Unplanned 30-days
readmissions, length of hospital stay, excessive costs and mortality. Drug and alcohol
dependence. 137. pp.55-61.
Harris, D. G. and et.al., 2015. Epidemiology and outcomes of acute kidney injury in critically ill
surgical patients. Journal of critical care. 30(1). pp.102-106.
Isenman, H., Michaels, J. and Fisher, D., 2016. Global variances in infection control practices
for vancomycin resistant Enterococcus–results of an electronic survey. Antimicrobial
Resistance & Infection Control. 5(1). p.41.
Janis, I. L., 2016. Psychological stress: Psychoanalytic and behavioral studies of surgical
patients. Academic Press.
Laflamme, M. and et.al., 2015. Preliminary experience with combined inhaled milrinone and
prostacyclin in cardiac surgical patients with pulmonary hypertension. Journal of
cardiothoracic and vascular anesthesia. 29(1). pp.38-45.
Larochelle, M. B and et.al., 2016. Dexamethasone Intravitreal Implant in the Treatment of
Uveitic Macular Edema in the Perioperative Cataract Setting: A Case Series. American
journal of ophthalmology.166. pp.149-153.
Macht, R and et.al., 2016. Challenges in Surgical Quality at Safety-Net Hospitals. JAMA
surgery.151(9). pp.795-796.
Martin, C., Jacob, M. and Kurz, A., 2013. Effect of waxy maize-derived hydroxyethyl starch
130/0.4 on renal function in surgical patients. Anesthesiology: The Journal of the
American Society of Anesthesiologists. 118(2). pp.387-394.
Mueller, N and et.al., 2016. Can sarcopenia quantified by ultrasound of the rectus femoris
muscle predict adverse outcome of surgical intensive care unit patients as well as frailty?
A prospective, observational cohort study. Annals of surgery. 264(6). pp.1116-1124.
Nicholson, A., Lowe, M. C. and Smith, A. F., 2014. Systematic review and meta‐analysis of
enhanced recovery programmes in surgical patients. British Journal of Surgery. 101(3).
pp.172-188.
11

Okabayashi, T., 2014. Intensive versus intermediate glucose control in surgical intensive care
unit patients. Diabetes Care. 37(6). pp.1516-1524.
Palant, C. E and et.al., 2017. Long-term consequences of acute kidney injury in the perioperative
setting. Current Opinion in Anesthesiology.30(1). pp.100-104.
Piazza, N., Kalesan, B. and Kappetein, A. P., 2013. A 3-center comparison of 1-year mortality
outcomes between transcatheter aortic valve implantation and surgical aortic valve
replacement on the basis of propensity score matching among intermediate-risk surgical
patients. JACC: Cardiovascular Interventions. 6(5). pp.443-451.
Scott, J. W and et.al., 2017. Contextual Challenges to Safe Surgery in a Resource-limited
Setting: A Multicenter, Multiprofessional Qualitative Study. Annals of Surgery.
Umpierrez, G. E., 2013. Randomized study comparing a basal-bolus with a basal plus correction
insulin regimen for the hospital management of medical and surgical patients with type 2
diabetes. Diabetes care. 36(8). pp.2169-2174.
von Dossow, V. and Zwissler, B., 2016. Recommendations of the German Association of
Anesthesiology and Intensive Care Medicine (DGAI) on structured patient handover in
the perioperative setting. Der Anaesthesist.65(1). pp.1-4.
Young, S and et.al., 2016. Challenges and Opportunities in the Provision of Surgical Care in
Vanuatu: A Mixed Methods Analysis. World journal of surgery. 40(8). pp.1865-1873.
Online
Handzo, R. G., 2012. Good communication in health care is about listening. [Online]. Available
through: <http://www.kevinmd.com/blog/2012/01/good-communication-health-care-
listening.html>. [Accessed on 24th July 2017].
12