The Connected Care Team

Celebrating Nurses Month

May 26, 2022 TigerConnect Season 2 Episode 19
The Connected Care Team
Celebrating Nurses Month
Show Notes Transcript

In this episode of The Connected Care Team, three members of the TigerConnect team, Cheryl McKay, nurse executive, Ryan Bush, clinical nurse consultant and Kourtney Govro, healthcare consultant, celebrate Nurses Month by discussing the state of modern nursing and how clinical collaboration and communication tools can prevent burnout among nursing professionals and lead to better patient outcomes.


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[00:00:00] Will O'Connor: So with us today on the show in honor of Nurse's week, we have three guests with us: Kourtney Govro, Cheryl McKay, and Ryan Bush. Cheryl McKay is an experienced Nurse Executive. She has her PhD and she has a variety of clinical and technical experience. She has a passion for clinical communication, collaboration, and care coordinator, and has been extensively published and does a tremendous amount of research in the area of healthcare, communication, and coordination.

[00:00:36] So we're lucky to have her today. We also have Ryan Bush, who is a clinical consultant at TigerConnect with extensive expertise in the area of nurse call as well as alarm management and has been recently involved in a lot of the implementations we're doing at client sites. and he's been with the organization for over a year, again, focusing on, alarm and alert management products. We also have with us, Kourtney Govro, who has worked in the healthcare industry for over 20 years and has expertise in mobile strategy as well as analytics related to health care and care coordination. So welcome to all three of you.

[00:01:17] Kourtney: Thanks Dr. Will. 

[00:01:19] Cheryl M: Thank you. It's a pleasure to be here with everybody. 

[00:01:22] Will O'Connor: Great. How has everyone enjoying Nurse's Week so far?

[00:01:26] Kourtney: That's very Good. 

[00:01:27] Ryan Bush: It's been good. It's been great. 

[00:01:28] Cheryl M: Awesome to see the celebrations and appreciation going on across the country. 

[00:01:33] Will O'Connor: Good. We're certainly happy to have you, today, so let's let us, let's get right into it. I wanted to start today with talking about what you're hearing from your nursing colleagues. I don't think there's ever been a more challenging time to be a nurse. And I would love to hear from each of you what you're hearing from the nurses that you talk to on a daily basis.

[00:01:57] Cheryl M: I'll go ahead and start with that, Will. I think the biggest thing that I'm hearing is a concern for staff, staff at the bedside, managers, directors, especially from our leadership teams. Burnout, fatigue exhaustion and really a concern about how do we take care of our nurses. Deading into COVID, we were already experiencing a nursing shortage, um, that has exacerbated the shortage.

[00:02:29] And so that has been on the forefront of everybody's mind. And I was privileged enough to get, to spend time with, nurse leaders at AONL just a few weeks ago. It's a time of concern, but it's also a time of celebration. It was great to be there in person to celebrate. Wonderful speakers, the Northwell nursing choir. And so I think there's a certain opportunity to celebrate and appreciate our nurses and really continue to work at creating that healthy work environment so that they can feel good about what they're doing.

[00:03:10] Ryan Bush: Just to piggyback off of that. you know what Cheryl said, I think one of the major challenges for nurses is maintaining an elevated level of resilience. Right? Nurses by nature, we're resilient individuals. However, there are many aspects of being a nurse that challenge even the most resilient nurses, you know, Cheryl mentioned staffing, challenging schedules working over time.

[00:03:34] Learning curves with constant changes in nursing practice and the technology that drives those changes. you know, we're, we're asking nurses to be more technologically advanced than ever with you know, EHR improvements and updates, bedside applications, communication, devices, software. So I think the challenge is, is really maintaining that level of resilience. But, at the same time, I agree with Cheryl, you know, and even in my local community, just did the signs that were in the front yard. And the thank you to nurses in the community, I think really has put a spotlight on nurses more than ever, which has just been fantastic. So with those challenges has just been great opportunity for nurses to shine even more.

[00:04:14] Kourtney: We've been doing quite a bit of research, as a clinical team at TigerConnect on the problems facing nurses with burnout, exhaustion, fatigue, and I've been meeting and interviewing with several nurses in my community and around the country about the topic and learning about secondary victim trauma and things like that that are really pushing.

[00:04:36] I do think that the ideas around burnout and what we're seeing in the nursing community is the challenge for the next five years. That should be the focus of every healthcare technology provider and hospital over the next five years, because we don't have enough nurses to meet the demand that's coming with the silver tsunami.

So this topic of how do we support our nurses? How do we turn it around? How do we make things better for them has to be top of mind for every single person within the healthcare it industry and with healthcare in general. And that's what I'm hearing back from our nurses is they don't need another pizza.They don't need another hat. They don't need another plate of cookies. What they need is support and someone that's actively listening to them, willing to hear the truth of what they're saying and they're experiencing on the floor and how are they taking that and putting it into action for them. And so that's what I'm hearing from my nurse friends.

And I will say that during these interviews, it is hard not to just cry with them after hearing what they went through at COVID and what they're going through now, which is this secondary trauma from the COVID experience it's they were heroes and now they're zeros, you know, so there's this, this strange balance that's going on in the nursing community that I just, I appreciate that we're taking the time to talk about because it is the next challenge. It is the big challenge for the next five years.

[00:05:52] Will O'Connor: Yeah. Yeah. I agree. Everyone that I talked to who's involved in running a health system, that I've really talked to the last couple months, their number one risk is related to a nursing labor shortage and labor costs and the skyrocketing costs associated with nursing. So, you know, all of you talked about supporting nurses and being more supportive. How do we do that? You know, Kourtney, you mentioned right they don't need another or another pizza or another sign or recognition. How do we support them and give them the tools they need to do their job better and possibly reduce some of the stress and burn out they're undergoing?

[00:06:41] Cheryl M: I think there's a lot of opportunity there, Will. And it's a privilege for all of us to get to work with staff at multiple levels when we work with our clients. Focusing on what we can do to help them in their work environment to make their life better with our technology, with other technologies, so that they have time to focus on what's important to them.

[00:07:07] Nobody went into nursing to be an engineer or a technologist. Do we do it? Absolutely. But, is it what we want? And I think the majority of nurses would tell you, they've got to spend time with their patients. They love their patients. They want to interact with them. They want to make them better. And you know, there's no one better to do that than nursing. They're the most trusted profession. So it's our responsibility to not just take that technology and implement it, but to make it better, to make things work better for those staff members who are really feeling it right now.

[00:07:41] Will O'Connor: You talked about making it work better. Let's get really specific on this. Ryan. What, what can we do technically to, to make it better for nurses and make their jobs easier?

[00:07:58] Ryan Bush: You know, I really think part of it is, you know, my experience has been the way we make things better technologically it's giving nurses a voice. So, I really encourage a lot of nurses to come to, you know, shared governance, you know, really getting, you know, informatics and those, those people in their nursing profession that are really engaged in what nurses are doing at the bedside, from a technological standpoint.

[00:08:22] But, you know, nurses are, are naturally innovators and they know they know the most what's going on at the bedside and we need to give them a voice so that we can, as a, you know, my background being in informatics is we can take that voice and take that feedback and really understand what the challenges are and then come up with a plan and work together with them.

[00:08:42] So I, you know, I really encourage nurses to, to come to a platform like shared governance and, you know, not just sort of hold in a lot of these frustrations that they have, but, but give them a chance to speak and actually do something about it and understand what the problems are. And then, you know, come up with a game plan to, uh, to make that experience more, pleasurable for them.

[00:09:01] Kourtney: Yeah, we used to call nurses the MacGyvers of the hospital. It didn't matter what was put in front of them. They were going to use the you know, the paper clip and that rubber band and make it work. They were going to make it happen no matter what ‘cause they had someone's life in their hand and they cared about whether or not that person's life was, kept alive and kept healthy and kept in good form.

[00:09:21] I agree with Ryan, you know, the research shows that the way that you help deal with compassion, fatigue, burnout is actually to allow them to communicate, allow them to speak, allow them to talk about their experience about the trauma they experience every single day. I mean, it's not like they don't go into a traumatic situations unlike most jobs that you go to. I would agree that our job as technologists is to look at how the things work and how we can remove things from their day.

[00:09:49] Our big focus in 2022 from an analytic standpoint is how do I make analytics active? How do I take it to where I'm looking at what's going on? I see all the things that are coming up. And I actively am moving them around so the nurse doesn't have to deal with them. There are things that our nurses don't need to deal with, that we force in front of them every single day. And I agree with Cheryl, the more we can take off their plate in a real meaningful way, and we can use research and manage that expectation a little bit, the better they'll be.

[00:010:20] And I believe it won't solve for burnout. It won't solve for compassion, fatigue, things like that, but it will help. It's one of the pieces of the puzzle that we can help solve.

[00:10:28] Will O'Connor: You know, I'd really like you to talk to me about what specifically can be done at the technology level to relieve this burden. It is very important that nurses are heard. And I think they are, gaining a stronger voice, at a lot of the clients that I've worked with, but what should they be asking for? What kind of technology can really help them alleviate some of this burden and burn out that we’re seeing? 

[00:10:58] Ryan Bush: Yeah. So, you know, implementing, you know, a CC&C tool, communication, collaboration, tool. It really, it really does take a lot of the inputs that nurses are getting: the buzzing, the ringing, the dinging, and it creates, it creates a process, creates standardization. It streamlines, you know, all of that information, all of that input into a way that nurses can, can actually, you know, successfully deal with with all of that input.

[00:11:31] Right. so, so one of the things that, you know, I like to use the term, we, we, we want to give nurses workload balance, right? So, so we want to give nurses the ability that they're sharing the workload amongst their peers. We're not just, having nurses, you know, a single nurse or CNA, getting every alarm or every alert, and being overloaded and not sharing that, that workload with, with others.

[00:11:55] So, so the way we design workflows is to be efficient, get the call to the right person at the right time. You know, whether, whether it's a water call, you know, we're not, we're not interrupting nurses we’re sending that to the appropriate individual. So it's, it's taking this disorganization of all of this noise and alarming and really streamlining it and putting in practical measures that that actually makes sense, from a workflow standpoint and how nurses can be more efficient. 

[00:12:22] Kourtney: I agree, Ryan. I think one of the things that it, you know, we do really well as a company is we go in and do the analysis prior. So figuring out, we know walking in the door that 62% of the calls from a nurse call do not require a nurse and that doesn't allow the nurse to work top of licensure. So she can't go in, or he can't go in and start doing the things that they need to do to care for patients, because they get bogged down with these, what we would call a concierge level requests, which can be dealt with, with somebody of a different, level at the hospital.

[00:12:54] And we have ability to look at the data and say, what's being asked for when, you know, what's being asked for when and how do I change the workflow? How do I change the care model on the unit to really tackle those issues for our caregivers so that we're not bogging them down and taking them away from doing the things that only a nurse can do.

[00:13:12] I mean, getting a glass of water is great, but the nurse, somebody else can do that. And the nurse can be spending that time, spending time with the patient, educating them on their condition, talking to a family member, talking to them through the pain that they're in. And how do we manage that pain a little bit better and not getting things like a glass of water.

[00:13:31] Ryan Bush: You know, nurse nurse call is a, is a simple concept. You know, that people think of it as a simple concept, but there, there really is a lot of complexities around, for solving for everyday problems. You know, we, we talked about response times. There's, there's a patient satisfaction component to it, right?

[00:13:47] HCAHPS scores. Reducing falls and proving purposeful rounding, you know, alarm fatigue, which we've already talked a lot about. You know, so having said that the workflows that we implement are designed to target all of these areas specifically. So we talked about the water call working at top of license. 

[00:14:04] We also target workflows around, you know, bed exits or bathroom calls because just statistically, we see most of our patients falling in the bathroom. So we want to design a workflow and use our product, to be conducive, to keeping patients safer and meeting their needs in a timely manner. So, you know, burnout and alarm fatigue has been obviously a major topic over the years. So that's why I like to use that phrase, you know, load balancing so that we're, we're really using the whole care team to balance the load effectively and efficiently. 

[00:14:35] Cheryl M: I agree with both Kourtney and Ryan. I think we can extend that though. What we do is provide context, for communication and the ability to integrate to other systems, to make sure that the right person, the right nurse, the right doctor has the right information at the right time. And whether it's answering a nurse call or it is creating the ability to manage a patient through the ED in a more timely fashion by pulling in the hospitalist or others.

[00:15:15] We extend to the entire care team and to the entire healthcare ecosystem, outside the walls, as well as inside the walls. And so all of those opportunities for efficiency and the ability to provide context, make for a better healthcare experience and better quality outcomes.

[00:15:34] Will O'Connor: So, so talking about that healthcare experience, I wanted to talk about that for a minute. What's the difference for the patient when you have technology like this installed?

[00:15:51] Kourtney: When you think about the technology and how it affects patients, that was how I started my career out, was looking at patient satisfaction and how the patient is engaged with quickly. When you have a CC&C tool, you automatically get a quicker, faster response time by nursing, if it's designed well.

[00:16:09] When Ryan was talking about response times, one of the things that we do is we look at quantity and we look at, pace, and we look at time. And so we look at how the amount of calls coming to the nurse, changes how quickly she can engage with the patient. And by default, then you're able to get to the patient more because you're doing that workload balancing like Ryan mentioned, and what we have found at several of our clients, we have seen increases in patient satisfaction by significant percentages, simply because we've designed the workflow to better manage or better maximize the use of the nurse's time so that she can care for the patient. 

[00:16:47] Ryan Bush: Yeah, some of the, some of the ways we can impact patient satisfaction is, you know, Kourtney mentioned getting to the patient quicker. You know, patients are, are really looking for that, you know, for that, you know, fast response time to meet their needs. Some of the other things, you know, that we really focus on is the noise environments for patients. You know, patients need a healing environment, when they're sick. 

[00:17:14] You know, so we take our technology and we, you know, we really take the alarms and the beeps and we try to try to really make them specific to a person rather than just letting the whole unit, you know, sort of ring and ding. And, you know, when a patient's sleeping and trying to get rest and recover, you know, that's a major dissatisfier. So we, you know, we work with nurse call vendors to delay some of those sounds that are coming from the core system and really use our product to be that, that key, that first line of defense, in terms of the noise of the notification, going to the nurse, that the patient doesn't have to hear. 

[00:17:46] A lot of those bedside monitor alarms or nurse call alarms going off. So I really think that there's a, there's a component of the noise level and the environment that's, that's conducive to healing when our product is implemented appropriately. And, you know, we also do a lot of rounding, you know, using our product for rounding purposes and getting feedback from the patient. And what's, been a satisfier dissatisfier for you, during your stay and, and using that feedback to then, improve workflows and make changes that are conducive. 

[00:18:13] Cheryl M: And I think that extends beyond patient satisfaction. Sometimes they don't know what they don't know. And that's where we impact the quality. For instance, working with an academic medical center, they were having problems with their stroke team response in the emergency department and had a long stroke response time greater than sixty minutes.

[00:18:37] And working with them, utilizing our technology, as well as an AI tool, we were able to help shorten that response time down to 30 minutes. And so when you think about that, in terms of the response time, that's 75 lives a year, that could be saved. That's readmissions that don't have to happen.

[00:19:00]And so we want patients to be satisfied, but we also want them to have the best quality of care, which, you know, that's, they might not know when they come in. So we have the opportunity to affect patients from every level of care. That is very humbling and very satisfying, I think, for our team and for their teams. 

[00:19:23] Will O'Connor: That's an amazing, that's an amazing outcome, to save that many lives in a year with a relatively, you know, simple workflow for one specific condition. What happens when you extrapolate that across an entire health system? Are there other outcomes that you've seen when deploying this technology? 

[00:19:49] Cheryl M: Oh, absolutely. We have seen phenomenal results for things like, the ability to transmit wound pictures from home health, into the hospital setting. Reducing the time, reducing the amount of staff it takes, reducing the supplies. Improving sepsis response times for inpatients and making sure that the three and six hour bundles are met.

[00:20:17] And so we see impact across the entire continuum with our technology and it is, it keeps growing and I think we keep learning more and more and can be more impactful. The larger, the volume. 

[00:20:34] Ryan Bush: So the the, the tool in terms of you know, improving some of those, those, core things that we look at, you know length of stay and capacity, we really leverage the technology to you know, as we mentioned before, getting to the right person at the right time, an example of that, you know, can be seen from ED to inpatient admissions and this the same goes for, discharges as well as is creating, you know, those roles in those team conversations that are very specific to those that are involved in the process of the processes to get the patient, effectively moved. you know, the throughput of the patient moving from, from the eED to inpatient, for example. There's a lot of toil that happens with, with that process without a good CC&C tool.

[00:21:24] You know, where where we see, the communication and collaboration team struggling to, to get the right people involved, in that process. And what our tool really does is the throughput and the efficiency of moving patients, communicating about what's happening currently, at any given time with a patient is really where we can make a big impact, to length of stay and discharge time and turnaround times. So that that's just one area, I think, that's, we've really seen a lot of success. 

[00:21:53] Cheryl M: And that that was really impacted during COVID because we really needed to get patients into the system, into the ICU beds, wherever they needed to go. A good example is one hospital I worked with in the Midwest. They were able to take double the volume in the emergency department and admit those patients faster. So the turnaround time, the ability to care for those patients, especially COVID patients who can sometimes crash very fast, made a huge impact on the way they delivered care and their ability to treat COVID patients in their community. And that was something that was replicated and that we've seen, time and time again, during this COVID crisis is the ability to use this technology to drive to patient safety and outcomes. 

[00:22:44] Ryan Bush: I want to share a really cool example that I, that I was able to, to see, our technology make a major impact, a client that was using a tele ICU during COVID. Where that voice and video communication was established in the room. And what we what we found is that with our product, we could, we could respond and interact through voice and video the same way they were doing with their own proprietary solution.

[00:23:13] We were able to talk to those tele ICU physicians and nurses, without going into the room, right, exposing nurses, in an isolation setting, you know, the cost with donning and offing. PPE. Right. You know, so, so we we've been able to take our solution and actually make other solutions that maybe don't work for, you know, for a pandemic or a specific situation, and actually really leverage the technology to, to save time, to save, you know, maybe exposure to sick patients, and to be really effective, efficient cost driven.

[00:23:46] So that, that was a great, that was such a cool experience for me to be able to be a part of that. 

[00:23:49] Kourtney: I think we look at capacity in a really unique way.When we think about capacity at a hospital, we're thinking about getting patients into beds. How do we move a patient through a bed? How do we think through this? How many patients can my nurse take care of? How many patients can a caregiver take care of? And oftentimes we're just looking at the acuity, but with our products and the way that TigerConnect really puts things together, they're able to look at more than just that. 

[00:24:14] So they're able to look at how much workload is actually being created by those patients. And it doesn't, it adjusts based on the patient's illness and their ability to use the systems. So when I'm super sick and I'm hooked up to all the different monitors and everything going on, actually creating a lot of work for those care teams. My telemetry monitor may be going off. I may not be using my call light a lot, but I'll be creating a whole lot of alarms from there and that's work. 

[00:24:39] And then I, maybe as I get better, I might be using my nurse call quite a bit. Cause I want to know when I'm going to go home. I want to know what's going to go on. Well, because we have the CC&C product installed, when you have that, you're able to say to the patient, let me check with your doc, text the doctor and get that information back and get things really flowing to get them up and out of the bed out of the hospital. Which we want patients that are not really sick, we want them at home. We want them to get home and get cared for at home and allow those beds to be used for the more sick patients. And that actually helps our nurses. You know, it's interesting, as we think a lot about capacity, like how many patients can we get in this bed to get more revenue through the hospitals in like that, but when you're moving patients through the system in an effective way, in an organized way, and you're giving the nurse the tool so that he or she can text with the people that are helping with that patient's care, you're actually really supporting the nurse and his, or her efforts to help that patient heal.

[00:25:37] And I think that's the most important thing you should think about when you're considering a CC&C product is what is this doing for my care team? Is it enabling them to collaborate better? Will this be able to make my patients heal faster? And will we be able to really move the sick people, keep them in the hospital, get the less sick people out of the hospital so that we can be more effective as a health system. 

[00:25:58] Will O'Connor: Sorry. You know what I think I'm hearing from, from all of you then is yes. You know, this technology has an impact on, on length of stay, capacity, on outcomes on patient satisfaction. But when you wrap it all up, It sounds like it has a significant impact then on alleviating some of the burnout and stress we're seeing in nursing, because you're making it easier for them to get patients moved through the system.

[00:26:30] Kourtney: Yeah. I mean, and if you think about turnover right now is a nurse turnover is averaging 20 to 25% across most of our hospitals. The cost to replace a nurse is very expensive. And not only that is, there's not enough, backload, there's not enough people to fill those spots. 

[00:26:46] And that's what I think as a health system and as a community we need to be concerned about is we don't have enough students coming straight out of the chute to fill the spots that are being vacated by the people. When the number three reason for nurse turnover is retirement, that's where we really need to get concerned because we need those older nurses that are in place to cultivate and coach the younger nurses. And we need those younger nurses right now that are all technology savvy and know how to use a smartphone and expect that.

[00:27:15] If I expect that in my daily life and I get to my hospital and they have a, dumb phone, you know, a plain old dumb phone that I have to make a phone call with, or even worse, a pager or even worse, nothing. Then my expectations as a young nurse are going to be, I don't want to be here. I want to be someplace that has cool tech that helps me do my job better. That helps me care for my patients that I'm used to using on a daily basis. I mean, we text my kids when it's time for dinner. We no longer holler. We say, hey, dinner’s ready, and then they decide whether they're coming up, if they're too busy playing a video game. But you know what I mean? That's what we have to, I think be really looking for as a hospital is how do I get these new nurses in the door in an environment where they can care for patients with the tools they're used to using that makes their  life easy.

[00:28:01] Will O'Connor: Yeah. Yeah. Yeah. That's a good point. you know, speaking of new nurses, you, mentioned new nurses and and students. What advice would you give to a new nurse starting out today? 

[00:28:16] Cheryl M: That's a really good question, Will, and, being the one who always likes to celebrate nursing, I would to tell them to make sure that this is their passion, right. To do something that they really enjoy and make sure that this nursing is, is what they want. The opportunity is endless and they will have the opportunity to carve their career path within nursing to what they want it to be. But we need nurses who still have that fire who still have that compassion. And so, I would say, make sure that, that this is, this is right for you and you know what? We want you. We absolutely want you to join and be a nurse and, we'll be happy to support you.

[00:29:07] Ryan Bush: And Cheryl to piggyback off of that, I, I think you hit the nail on the head. It's really around passion and within nursing, because nursing has evolved over the past 20 years. When you look at what nurses are capable of doing, you know, we're, we're not just bedside nurses anymore, right? We're getting, whether you want to be an informaticist or you want to be an advanced practice nurse or, you know, really the sky's the limit and how you can impact the profession and how you can impact patients. And I think that's really important for, nurses just starting out is really understanding and, and pursuing and in exposing yourself to all the different facets of nursing and what makes the most sense for you and how, how you can make that impact. 

[00:29:48] Kourtney: You know, my son Tucker is getting ready to head out to college in the fall to be a nurse. He wants to go to school to be a nurse. And when we were talking about this, we talked back and forth about, you know, what's the pros and cons of being a nurse. And I said, you know, this is a real deal job, man. If you screw up, you can really impact somebody's life.

[00:30:06] And I said, you need to be prepared for that reality. And you know, as a mom, I'm sitting there going, is my kid ready for that? Is my kid okay with that? Can he handle that? And he, he was really, I said, why would you really want to do this? And it was right after the pandemic. You know, we, we just, we were driving back for something and he goes, mom, nurses are heroes, and I want to be a hero too.

[00:30:27] And I was like, oh my gosh, you just broke my mom heart. But if you think about that, that's, that's what the perception of this young man was, is I want to go do this because I know they're heroes. I know they gave everything during a time when nobody knew what was going on and everything was difficult and it was hard and they did it anyway and they showed up. And so I think what I would encourage the young nurses is know what you're walking into eyes wide open. 

[00:30:53] And just remember that these are heroes. These are people that showed up when nobody else would, they didn't get to go home a lot of them, and they were willing to do it because they cared so much about people. And so I hope that, you know, these younger nurses remember that, that you're going into a profession to be a hero.

[00:31:11] Will O'Connor: I think that's a great point. and it really is true. And, I really appreciate all three of you being on the show today. And although, you are not doing a lot of direct patient care today, all three of you, you are greatly impacting the nurses that are, and the work that you're doing to enable them to do their jobs better, to drive better patient care. But also to alleviate some of this burnout we've been talking about and make their jobs more pleasant, more enjoyable, and more fulfilling. I congratulate all three of you for the work that you're doing to drive that. And thank you for taking time out of your busy schedules to be on the show with us today.

[00:31:58] Kourtney: Thanks. 

[00:31:59] Ryan Bush: Thank you so much. 

[00:32:00] Cheryl M: Thank you.

[00:32:01] Ryan Bush: It was a pleasure.