“Patients first” means patient safety first and satisfaction first When talking about labor and delivery analgesia, there is no longer a need to decide between ease and comfort and the safety of mother and baby. All of the various safe and effective modern technologies or modern medicine that we use every day of our lives come with some level of risk, from everyday modern transportation to oral contraception, and we are trading the benefits of modern life for a tolerable level of risk. Likewise, labor analgesia is the product of this trade-off. Happily, since the introduction of epidural labor analgesia, a concomitant decline in obstetrics-related mortality and complication rates has been noted in the United States over the same period. 1. The entry of anesthesiologists into the labor and delivery room has deeply influenced clinical practice in the field of obstetrics. In the 2004 edition of the American College of Obstetrics and Gynecology’s Guidelines for Obstetric Analgesia, obstetricians have been cautioned that “childbirth causes severe pain in most women, and mothers’ request for pain relief in labor is itself a strong clinical indication. Whenever and wherever there is a clinical indication and no contraindication, pain relief measures are obligatory. It is inhumane to put a woman in such severe pain under the watchful eyes of our physicians and not give her analgesic treatment that has been proven to be safe and effective” (2. Kind of like what we say: can we not see it coming!) . And the use of labor analgesia as an essential part of the obstetric anticipatory medicine model advocates the use of prophylactic epidural placement for women at high risk of cesarean delivery to cope with the possibility of emergency cesarean delivery during the trial of labor and to avoid the high mortality rate of general anesthesia. In the actual clinical practice of obstetric anesthesia, the labor and delivery unit in the United States has actually become a special ICU managed by anesthesiologists who have become experts in the labor and delivery unit for any clinical problem other than childbirth. They are involved in all clinical management including high-risk critical care obstetrics, from cardiovascular patients, pre-eclampsia, dyscoagulation, obstetric hemorrhage, cardiopulmonary, hepatic and renal failure, to obstructed labor, and even neonatal resuscitation. It is easy to explain that the proportion of obstetric deaths in the United States has not only relegated the mortality rate related to obstetric anesthesia from the 6th place in the late 1980s to outside the top 103, but also made obstetric hemorrhage, which is closely related to obstetric anesthesia, the number one cause of death in obstetrics in the United States for the first time in history at the end of the last century.4 Serious obstetric complications, which are 50 times greater than the mortality rate, have also been reduced.5 Obstetric anesthesia The introduction of obstetrical anesthesia into the labor and delivery room not only allows the pain of childbirth, which has been inherited for generations, to stop tormenting our mothers-to-be, but also the ICU’s similarity to minimize obstetrical mortality and complications, another monument of human medicine! Northwestern Memorial Hospital at Northwestern University Feinberg School of Medicine in Chicago, USA Northwestern University in the small town of Avenstein, Illinois, is located on the shores of Lake Michigan. Founded in the last century, it has been a noble institution and a top private research university for more than one hundred and fifty years. Its campus covers 250 acres of beautiful landscapes and has a current student population of more than 15,000. It is well known for its College of Arts and Sciences, School of Languages, School of Music, Medill School of Journalism, McCormick School of Engineering and Applied Sciences, School of Education and Social Policy, School of Medicine, and School of Law. The School of Business, which was ranked number one among the top business schools in the United States for six years from 1988 to 1994. The Medill School of Journalism, recognized as one of the best journalism schools in the country. Northwestern University’s School of Medicine, School of Law, and School of Business are located in downtown Chicago, and the affiliated Northwestern Memorial Hospital is also located on the downtown campus. On September 1, 1975 and 1979, Northwestern Memorial Hospital merged with Chicago’s oldest hospitals, Passavant Memorial Hospital, built in 1865, and Wesley Memorial Hospital, built in 1888, to create what was then the largest private, not-for-profit hospital in the Midwest. Over the past four decades, it has continued to expand its medical facilities, add clinical services, provide community services, and work to meet the changing health care needs of the Chicago area. By the mid-1980s, the original hospital facilities, were far too large to meet the needs. The most expensive, most advanced and largest medical construction project in the nation began to be conceived. The new 20,000-square-foot, 17-story Feinberg Building and 22-story Galt Building, which opened in 1994 at a cost of$580 million, opened five years later (May 1, 1999). In late 2007, the new state-of-the-art, comfortable, highly private, comprehensive, family-oriented Prentice Women’s Hospital opened as a model for patient-first care in the United States. Northwestern Memorial’s simple, straightforward “patient first” motto is so deeply rooted in the hearts of people that it is ranked among the top three most prestigious hospitals in the United States for patient satisfaction. Its aristocratic nature was once censured by the Wall Street Journal in 2008. It hosts hundreds of regional, national, and international study tours each year. Its partnership with Northwestern University dates back more than a century, and over time the hospital began a collaboration of clinical services and medical teaching, setting a long-term goal to establish the Mecca Northwestern University Medical Center in 1966 with it as the backbone. The two hospitals, Pashawan and Wesley, were used as the base for a complete rebuilding of the campus. At the turn of the century, Robert H. Lurie’s Center for Medical Research expanded the School of Medicine’s research in biomedical sciences. Northwestern Memorial Hospital went on to become one of the nation’s leading academic medical centers for clinical, teaching, and research, with a growing reputation throughout the United States. Historically, the hospital became a National Center for Perinatal Care in 1974; a Top Hospital in the United States since 1987; a National Institutes of Health designated Vascular Center and Lynn Breast Center in 1994; a Consumer Choice Award from the National Hospital Consumers Association as Chicago’s “Top Choice” hospital in 2001; and the hospital’s “Top Choice” hospital in 2004. In 2004, eight of the hospital’s clinical specialties were ranked on the annual list of “America’s Best Hospitals” in the U.S. Weekly World News & Report’s national rankings. 2005, the Bloom Cardiovascular Institute was established with a$10 million gift from the Neil Bay Bloom and family. 2006, the American Nurses Credentialing Center awarded Northwestern Memorial Hospital with the Nursing Excellence Award. In 2006, the American Nurses Credentialing Center awarded Northwestern Memorial Hospital the Gold Standard of Nursing Excellence; in 2007 and 2009, two grants totaling$40 million were made to emerging clinical technology translation programs and cancer research; and in 2010, the Lake Forest Hospital merger was completed, beginning the clinical expansion of the Chicago neighborhood. Over the next 10 years, the School of Medicine and the hospital will continue to work together to create one of the nation’s few world-class medical centers. The Department of Anesthesiology at Northwestern is headed by a Chief of Service who is fully accountable to the hospital and the medical school, is paid by the medical school, is financially decoupled from the department, and has absolute authority over the department’s personnel and finances. There is a Vice Chairman and an Administrative Director. The former assists the director in charge of the three pillars of the department, such as clinical, research and teaching, with the help of the assistant clinical director, assistant teaching director, and assistant research director (Associate Chairman). The Administrative Director and Chief Financial Officer, with the Director of Finance, Director of Human Resources, Director of Education, and Director of Research, is responsible for the day-to-day operations of the department, including the entry and exit of staff, daily clinical staff adjustments, patient fee collection, resident training, and the approval and supervision of various research projects. The total number of administrative staff such as secretaries for each department is 26. Clinically, there are two levels of physician responsibility: attending and resident. Clinically, the Attending Physician (Attending) is solely responsible for the final preoperative evaluation, intraoperative anesthesia, postoperative analgesia, postoperative complication management, and medical litigation. Anesthesia residents (Residents) and nurse anesthetists (CRNAs) must work under the direction of the attending physician. A fellow is a transition between a resident and an attending, a senior resident with attending privileges who has received specialty training and works under the supervision of an attending physician. Anesthesia fellowships include pain, critical care, obstetrics, cardiovascular, pediatric, neurological, ambulatory surgery, and regional anesthesia, and generally have a counterpart specialty society for one year. There are special unified exams and certificates for both pain and critical care as diplomas for professional induction. Anesthesia Technician (Anesthesia Technician) helps with instrument preparation, anesthesia cart preparation, and consumable replenishment for routine and emergency situations in the operating room; Research nurse (Research nurse) helps with data collection for research, follow up, and assists with project approval for medical school research committees; Registered Nurse (Registered Nurse) is responsible for post-operative The Nurse Practitioner is responsible for various clinical management of post-operative analgesia and daily analgesic rounds with the anesthesiologists in the anesthesia acute pain specialty group. In 2010, the department had 74 attending physicians, 63 anesthesia residents and about 13 specialist trainees, 54 anesthesia nurses, 6 research nurses, and a hospital staff of nurses, advanced practice nurses, anesthesia technicians, and clerical staff related to clinical practice. Prentice Women’s Hospital and its maternity ward Prentice Women’s Hospital, part of the Northwestern Memorial Hospital Group, moved to a new 1 million square foot site on October 20, 2007. The new hospital was designed to emphasize a “patient first” approach to patient satisfaction and medical safety. It is the most advanced women’s hospital in the United States in terms of hardware and software (hospitals in the United States do not usually include outpatient clinics), designed with women in mind, and with the utmost humanity and care. The hospital offers the most comfortable and convenient medical environment, the latest medical equipment and technology, and the best health care professionals, from pregnancy care and obstetrics, to gynecology and menopausal bone health, to breast surgery and plastic surgery, providing comprehensive, top-quality medical services to meet the special needs of women for all their medical health issues and well-being at all stages of life. The hospital has a gift store, a café, a 24-hour restaurant (offering computer-connected ward orders and room service), a special room for breastfeeding and breast pumps. The hospital’s patient library offers lectures on special topics, a variety of scientific and specialized books, and video and audio mold instruction. The wards have free high-definition large-screen LCD TVs, BOSE speakers, and wireless Internet access. In addition to various popular cable TV channels, there are special science education films on common medical problems, music channels with beautiful scenic images, and a 24-hour restaurant with recipes and a la carte channels. A warm, homelike and humane medical environment is created for patients. There are 10 general surgeries and 30 single-room resuscitation rooms in the hospital, which are responsible for all surgical specialties except obstetrics, with 6,122 surgeries in 2009. The third floor of the hospital is a most modern conference center with a capacity of 1,000 people. The maternity ward of Prentice Women’s Hospital consists of 36 single family-style delivery rooms, and 4 obstetrical operating rooms. It is well designed, with the operating room, obstetrics and anesthesiology offices side by side in the center of the 8th floor, and the delivery rooms are distributed around this center to ensure that in the event of an emergency during labor and delivery, the doctor can reach the delivery room as quickly as possible, and also to ensure that in the event of an emergency cesarean section, the mother can be transferred to the operating room for emergency surgery in the shortest possible time to meet the needs of the mother’s heartbeat and respiratory arrest. The team is composed of 125 obstetricians. The medical team consists of 125 obstetricians, 31 midwives, and more than 180 obstetric nurses, full-time or part-time. The obstetric anesthesia team is stationed in the delivery room 24 hours a day, regardless of weekends or holidays. The world-renowned Professor Cynthia Wong is the head of the obstetric anesthesia department. The obstetric anesthesia staffing for the Sunday day shift (6:45am-5:00pm) is arranged as follows: 7 residents (usually one 4th year resident, 5 3rd year residents, and one 2nd year resident), and 2-3 anesthesia specialist fellows, and one nurse anesthetist. 3 attending physicians are assigned to labor analgesia in the delivery room and the operating room (elective and emergency cesarean sections, multiple births – 2nd The hospital’s annual labor volume is 13,000. The hospital’s annual maternal volume is 13,000, the labor analgesia rate is over 90%, and the cesarean rate is around 26%. The daily volume of elective cesarean deliveries is 6-8. Examples of clinical problems and solutions In the United States, obstetrics and obstetric anesthesia are considered “high-risk” specialties in the field of anesthesiology and are highly valued. Medical malpractice in obstetric anesthesia accounts for a disproportionately high percentage of lawsuits in the U.S. In the late 1980s, complications from obstetric anesthesia accounted for the sixth highest number of maternal deaths in the U.S. among all pregnancy deaths. Management is well aware that human error accounts for a certain percentage of medical errors, but ultimately can be avoided through good systems management, and hospitals have a suite of management systems targeted to address clinical day-to-day matters, of which the following are just a few examples. Information Systems: The lack of knowledge of maternal medical history is a prominent problem in the United States where obstetric anesthesia accounts for a disproportionately high percentage of lawsuits and maternal deaths due to complications of obstetric anesthesia, especially in large multidisciplinary delivery rooms. Hospitals are well aware of this problem and have learned a great deal. A lot of human and material resources are used to ensure the smooth flow of information. Hospital paging telephone system: three sets of telephone systems are used in the delivery room, hospital landline telephone for daily affairs, hospital wired emergency red telephone system for medical emergencies after the hospital’s ordinary telephone barriers, and a special phone for the delivery room equipped with a fast feedback function. The special cell phones for maternity wards are dedicated to the duties of the work, such as obstetric anesthesia analgesic attending, obstetric anesthesia surgical attending, anesthesia inpatient chief administrator, anesthesia inpatient 2, 3, 4, anesthesia nurse, anesthesia research nurse, anesthesia technician and other groups of cell phones for anesthesia, and several groups of cell phones for other specialties. The cellular phone is equipped with a quick feedback function for each cellular phone holder to be able to reply with a single key after receiving an emergency alert, but to let the system know that “I know” and to provide information for future work and duties. The cell phone system also provides a chain search for the next level of calls in the absence of a cell phone response, ensuring that someone will answer the phone and deliver the message. All doctors have traditional private BBs, and special BBs, such as airway, surgical attending, analgesic attending, etc. as a backup system. System: It is a hospital intranet patient information system for the delivery room, including patient name, room, nurse, nurse’s phone number, obstetrician, labor, opening, previa, fetal position, amniotic membrane, amniotic fluid, anesthesia and analgesia status, special obstetric conditions. There are also the fetal heartbeat and contraction dynamics of the mother. These are on computer screens in all offices, from the prenatal room, to the labor and delivery room, to the operating room, and on multiple 50-inch flat-panel monitors in all offices. It’s a real “heads up, heads down” situation. In a multidisciplinary clinical group, dynamic information transfer is an essential part of the system, and this system saves many links. Anesthesia-Obstetrics Clinic and Pre-Anesthesia Evaluation: The old Chinese proverb “If you know yourself and your enemy, you can’t win a hundred battles” was validated in a study in Michigan. Of the eight anesthesia-related deaths in their 16-year statewide study, four were due to a lack of patient history. And that doesn’t even include those complications. To fight the preparedness battle, the obstetric anesthesia department routinely has a medical history physical exam and writes an anesthesia history for every woman admitted to the delivery room. Emphasis is placed on a detailed obstetric history related to anesthesia and a careful airway examination, and a necessary back and spine examination. Although platelet and coagulation tests are not routinely performed on healthy women, those with diseases that alter platelet concentration (e.g., gestational hypertension) and other clotting disorders are not spared. The hospital has a monthly obstetric anesthesia clinic dedicated to sending their high-risk patients to obstetricians. Clinical decisions should be made on a case-by-case basis for each patient. To ensure the safety of the mother and newborn and a smooth maternal delivery, the anesthesiologist, obstetrician and pediatrician, discuss each patient’s specific situation. All three must remain in effective and close contact throughout the medical process. In the case of a complex patient with a maternal history and physical examination, a multidisciplinary discussion is held, and the obstetric anesthesia FELLOW transmits the complete medical history to all attending obstetric anesthesiologists, who then give their opinion and practice, and finally summarize it for the record, becoming a typical example of the “Three Stooges”, saving the lives of countless mothers and babies and reducing countless complications, as well as avoiding many medical disputes. Offices and meetings: The clinical offices are organized by the rank of the medical staff, not by the usual specialty groups. The various information systems described above are located in various corners of these offices. Among them, the offices of the attending physicians and nurse supervisors also have dynamic flow of the gynecological operating room and monitoring data of the patients in the operating room. There are two daily meetings for obstetrics, anesthesia, and nurses to ensure that there are no blind spots in information for all levels of health care professionals across the board. In short, the acquisition and transmission of information, past, present, new, and rolling, contributes to a comprehensive and complete plan that, simply put, transforms emergency care into “elective” care, fully embodying the anticipatory medicine model. Intrauterine distress: The hospital’s delivery room hardware is carefully designed to allow for rapid transfer of patients to the operating room for cesarean section in the event of a maternal emergency, so that the obstetric guidelines for removing the fetus within four minutes can be implemented. For this purpose, a dedicated operating room is on call twenty-four hours a day. In this operating room, all sterile surgical instruments are in place, and the instrument nurses open them as soon as there is an alarm. After the daily shift change in the anesthesia department, there is a person to check the anesthesia machine, monitor, suction, all general anesthesia tracheal intubation instruments and catheters, thiopental sodium for general anesthesia induction, syringe labels for syringes of drugs to prevent gastric shunt, and 3% chloroprocaine for vertebral anesthesia to ensure that there is an epidural for emergency rupture of labor. In the event of a maternal emergency in the delivery room, the nurse pushes the alarm button in the delivery room and the hospital’s communication alarm system sends a simultaneous alarm and location to the on-call cell phones of all obstetricians, anesthesiologists, neonatologists and surgical nurses. The neonatologists, surgical nurses, and a group of anesthesiologists go directly to the emergency operating room, while another group of anesthesiologists, obstetricians, and obstetric nurses go straight to the delivery room to transfer the patient to the operating room. During the transfer process, the anesthesiologist who has epidural placement for labor and delivery analgesia will complete the surgical dose of local anesthetic injection while reporting patient information via cell phone with the anesthesiologist-in-charge in the operating room. Patients are passed over the bed and then splashed with antiseptic solution directly by the traveling and obstetrical nurses, assisted by the obstetrician who has washed his hands to spread the towel, and a brief pre-surgical call-off. The anesthesia team performs an immediate block level assessment while putting in monitoring and decides if immediate change to general anesthesia intubation is needed. After the attending anesthesiologist announces that anesthesia is complete, the obstetrician begins cutting the skin, delivers the fetus within one minute (the entire procedure is guaranteed to be completed within 4 minutes), and transfers to the neonatal team that is ready to perform the abdominal incision with hemostatic sutures. The medical ethics of the procedure is to give priority to the safety of the mother and to ensure the maximum safety of the newborn. Rapid and safe pain-free delivery: In order to reduce maternal pain as quickly as possible, the anesthesia team takes a series of clinical and administrative measures. As soon as the patient arrives at the delivery room, a medical history and physical examination are taken, and coagulation is not routinely tested if there are no signs of coagulopathy, no severe pre-eclampsia, or liver dysfunction. As long as the mother requests, labor has been started and there are no contraindications, labor analgesia will be started immediately regardless of how many centimeters the uterus is open. Routinely try to use combined lumbar and epidural analgesia to give the woman analgesia about 5 minutes after successful epidural placement, instead of waiting 20 minutes or so for simple epidural analgesia. If no attending physician is available after 30 minutes of requesting labor analgesia, the obstetrical nurse may cross over to the attending anesthesiologist, who will immediately do the operation himself and pursue the cause. While advocating rapid labor analgesia, the advantages and disadvantages are fully balanced, highlighting the safety of mother and child first. Simple epidural labor analgesia is more often used for women who have a higher likelihood of turning to cesarean section in the pending labor, or who have a high-risk airway, or who have a high incidence of epidural catheter failure, such as second try after cesarean section, pathological obesity, severe preeclampsia, those with scoliosis or who have had spinal surgery, and those with a grade IV airway assessment of Mohs. These patients need to be closely observed during labor analgesia to detect those unexplained various malfunctions of the epidural catheter during labor, to eliminate them in time and, if necessary, to re-canalize them. All clinical measures are guided by evidence-based medicine to ensure the absolute safety of mother and child and to eliminate medical disputes. Where the evidence is insufficient, clinical trials are conducted on their own. Cynthia Wong, director of obstetric anesthesia, published a paper in the New England Jounral of Medicine in 2005 on The Risk of Cesarean Delivery with Neuraxial Analgesia Given Early versus Late in Labor This is a case in point. Their study showed that early delivery with neuraxial analgesia did not increase the risk of cesarean delivery and that neuraxial analgesia shortened the duration of labor compared to systemic analgesia. The results of this study directly contradicted the traditional misconception that early labor analgesia (latency) increases cesarean delivery, and within a year led to the 2006 revision of the American College of Obstetricians and Gynecologists (ACOG) guidelines for obstetric analgesia and the American Society of Anesthesiologists (ASA) guidelines for obstetric anesthesia, which abolished the previous recommendation of (the correctness of this change has now been confirmed by numerous double-blind clinical studies). In fact, many of the classic studies of obstetric anesthesia came out of this hospital’s Department of Obstetric Anesthesia. Although Director CynthiaWong is one of the editors-in-chief of the world’s classic textbook, Chestnut Obstetric Anesthesiology, and Editor-in-Chief of the Obstetric Anesthesia Section of the world journal Anesthesia and Analgesia, and although the Director of Obstetric Anesthesia is a world-class authority, their various philosophies are not expertly stated; research evidence speaks for itself is the ethos here, and where evidence cannot be found, the department does clinical trials. Anesthesia residents must debrief the attending before each operation to discuss analgesic options. Colleagues in obstetric anesthesia recognize that obstetric patients are unique and that many pregnant women do not give birth in a single shift. The analgesic protocols and delivery of obstetric patients, more specifically, they are not patients in the operating room, and it is impossible for one physician to complete the entire anesthesia from start to finish. Therefore, they use a consistent clinical analgesic protocol (that is, the enclosed fine print) with the same drug (bupivacaine). To avoid using the wrong drug, the common drugs are dispensed by the pharmacy, for example, the epidural bag of bupivacaine, ephedrine, and neuflorin. Together with the fact that the test doses were produced by the pharmacy, no drugs were dispensed by themselves. This avoids the increased chance of contamination due to inaccurate dose concentrations and poor sterile conditions that may result from individual dispensing. This series of measures, which maximizes the elimination of possible uncertainty due to human factors, becomes a typical example of reducing human error with systematic measures to ensure safe patient care. Obstetric hemorrhage: Obstetric hemorrhage deaths in the United States have finally fallen from the top of the list of causes of death to second as we enter this century, and the current indications are that it will be the third cause of death after embolism and preeclampsia. Obstetric anesthesia in the United States has played a leading role in this. This is even more true for labor and delivery in the Northwest. Obstetric hemorrhage is no more than surgical hemorrhage and medical hemorrhage, and obstetrics and obstetric anesthesia share the responsibility for the management of hemorrhage. The knowledge, skills, and responsibilities of obstetric anesthesiologists determine them to be the protagonists of this problem. In terms of hardware, the operating room has a variety of specialized anesthesia placement carts, various catheters (arterial cannulae, central venous cannulae, pulmonary artery catheters, etc.) and invasive monitoring all in place; three levels of rapid infusion and transfusion heaters are dedicated, from simple manual pressure bags, HOTLINE, to LEVEL ONE double bags of electric pressurized and heated infusers, and the Belment automatic thermostatic infusion heater capable of reaching 1000 ml per minute for liver transplantation. Belment fully automatic thermostatic infusion and transfusion machine. The Department of Obstetrics and Anesthesia has developed blood preparation and transfusion guidelines for obstetrical patients based on the blood volume database of the hospital blood bank for obstetrics and gynecology in previous years. According to the specific situation that the operating room is far away from the blood bank, a three-stage blood preparation program of blood cross preparation (Typing & Cross), blood type antibody pre-testing (Typing & Screening), and blood specimen filing (Drawn & Hold) is adopted to shorten the time turnaround of blood testing in clinical emergencies. In addition, there is also a 24-hour storage of Rh(-)O blood in a refrigerator in the operating room of the maternity ward. This ensures the safety of the patient and minimizes the waste of blood bank resources. In response to the common need for blood allocation to keep up with the need for blood during obstetric hemorrhage rescue, a Massive Blood Transfusion Protocol (MBTP) has been set up that can only be initiated by the attending anesthesiologist. Once the process is activated, the blood bank will send a special refrigerator for blood to the designated place and automatically send blood products to the refrigerator until it stops, changing the traditional mode of “blood request – blood distribution – blood delivery – blood transfusion” to the ultra-short mode of “blood delivery – blood transfusion”. The ultra-short mode of “blood delivery-transfusion” has been changed. The efficiency was improved, and the blood source no longer became a bottleneck in the resuscitation of hemorrhage, which was extremely popular among medical and nursing staff at all levels. Subsequently, it was found that the medical staff was very inaccurate in estimating the amount of bleeding, which delayed the treatment of many bleeding patients. For this reason, a computerized education course was used specifically for on-site education in the relevant obstetrical departments to popularize the weighing method and mandatory reporting of patients with more than 800 ml of vaginal bleeding and 1000 ml of cesarean delivery. The obstetric anesthesia department must oversee and intervene in the consultation and treatment process. For placenta praevia, depending on the location of the placenta and the depth of implantation, prenatal obstetrics will work with anesthesia, nurses, and radiological interventions to develop the route of delivery, the place of delivery (extremely severe implantation of placenta praevia will be scheduled to a major operating room at Northwestern Memorial Hospital with a manual heart-lung pump and a concentration of anesthesia staff), and whether to place a femoral artery line for emergency uterine artery embolization to avoid emergency hysterectomy and the consequences of poor information flow Staffing issues: As the number of patients increases, the staffing of subordinate physicians/nurse anesthetists and superior physicians becomes part of the management. In addition to a purely revenue perspective, a realistic understanding of staff workload, fatigue, the total number of labor analgesics, the number of women unable to deliver analgesics within 30 minutes, the peak time of day for cesarean deliveries, and similar hospitals’ obstetric anesthesia staffing levels to determine the types of staff to match patient workload. It was only in a recent adjustment that it was discovered that they had the highest average volume of labor analgesia in the United States for obstetrics. Hospital numbers showed that there were instead fewer cesarean deliveries during the day when there were 2 attending than during the night shift when there was one attending. In response, the department added an obstetrical anesthesia attending, making four attending 24 hours a day, one on the day shift and one on the night shift, one for cesarean deliveries from 5:30 a.m. to 14:00 a.m. and one from 14:00 a.m. to 22:00 p.m. The additional attending was paid by the hospital. An additional nurse anesthetist was funded by the department. The problem of staffing constraints was solved. Quality control and medical litigation: Patient follow-up system: usually a resident doctor goes to the ward every day to do follow-up visits to find out how obstetric patients feel after anesthesia, neurological complications, and to detect emergencies that can be resolved without delaying clinical interventions, such as hematomas and central nervous system infections. For common peripheral nerve palsy, a clear diagnosis is made and the consultation and recovery of the rehabilitation physician is sought. For common headaches, strict diagnosis and differential diagnosis are made, and standardized management is implemented for those diagnosed with post-dural puncture headaches. After dural puncture, they do not require the mother to go to the pillow and lie flat, but only encourage the patient to quote caffeinated beverages, and oral FIEOCET and explain to the patient first after the headache appears, and if it cannot be relieved after taking the medication then blood filling therapy can be chosen. High-risk patients sampling system: Hospital Quality Control Hospital Quality Control Committee in the past quality control, statistics found that patients over 70 years old, emergency, extracorporeal circulation, artificial hypothermia, artificial controlled hypotension, special position and other patients are prone to problems. The committee synthesized the specifics and grouped the clinical issues involved into practices that most of their peers would agree with, half would agree with, and most would not agree with. The latter two of these will be filed with the hospital and the department head, and multiple incidents will affect the hospital practice license of the personnel involved. Death and complication discussion system: The department has a monthly death and complication discussion that centers on expanding the problem and educating everyone to prevent recurrence. If it is a systemic problem, or one that can be solved by systemic norms, an interim committee is formed by those involved to develop appropriate measures and follow through administratively. It is also with the goal of solving the problem that the parties to these medical records are anonymous. Risk Management: The “anticipatory model” for reducing medical litigation has also been adopted. Unexpected clinical events are encouraged to be self-reported, dictated, documented by hospital attorneys, and investigated by the appropriate personnel as necessary. This is completely independent of quality control, and the quality control committee does not communicate with each other to ensure privacy. The hospital attorney will also guide you on exactly how to approach different situations, what to discuss, what to avoid, etc. The hospital attorney’s committee, will file these cases in a separate category. For those cases that meet the high risk of medical litigation, targeted measures are taken to make every effort to reduce litigation and rewards. As you can see from the above, Northwestern’s authorities at all levels are doing their best to achieve one goal, which is to run the hospital with the goal of “patients first. “Patient first” means patient safety and satisfaction. Whether it is building a hospital, buying equipment, setting up professional committees, or implementing clinical special measures, it is absolutely subordinate to the purpose of running the hospital. When the purpose is set, the target group is determined. Hospital management is well aware of the gap between clinical work and labor compensation. What the hospital management needs to do is to get everyone working together to achieve a common goal. This is especially true in the maternity ward of a multidisciplinary clinical unit. Simply put, hospital management is getting the various hospital clinical disciplines to work together with the goal aligned with the purpose of the hospital, and money is just a medium, a commutation tool. Do not invert it.