System-Based Multidisciplinary Initiatives for Improvement in Tracheostomy Care and Safety: Experience of an Academic Health Institution Hospital Network


  • Joshua H. Atkins, MD, PhD Penn Medicine
  • Leah Lambe, BSN, RN Penn Medicine
  • Laura Marchiano, BS, RRT Penn Medicine
  • Lea Anne Gardner, PhD, RN Patient Safety Authority
  • Doreen Lam, BA Penn Medicine
  • Christopher H. Rassekh, MD Penn Medicine



tracheostomy, system-based practice, quality improvement, patient safety


Tracheostomized patients represent a unique patient population at risk of life-threatening airway compromise. There can be a presumption that these patients have a “safe” or low-risk airway. Clinicians and other care providers may be unfamiliar with both tracheostomy tubes and best practices for tracheostomy maintenance, assessment, and emergency triage or resuscitation. A review of the highest- acuity emergency airway calls at our university hospital revealed that well over 20% of the emergencies that triggered these activations were in patients with existing tracheostomy tubes. Further analysis of the tracheostomy-related airway emergencies at that time was very informative.

Under the auspices of our multidisciplinary airway safety committee, we developed a core tracheostomy-focused team and implemented numerous quality and safety initiatives. Here we present a focused review and discussion of tracheostomy-related clinical issues at the University of Pennsylvania Health System (UPHS) and a summary of quality and safety improvement efforts related to the care of tracheostomized patients based on responses to locally identified safety opportunities.

Our experience with tracheostomy-related quality improvement (QI) efforts led us to reach out to the Patient Safety Authority. The Pennsylvania Patient Safety Reporting System (PA-PSRS) data presented by Gardner et al. highlights the categories of airway-related events documented across a range of facilities in the Commonwealth of Pennsylvania. We frame our efforts in the context of both the PA-PSRS data and international perspectives from the U.K. and highlight barriers to implementation and learnings from our iterative and interdisciplinary approach to tracheostomy-related challenges.

Author Biographies

Joshua H. Atkins, MD, PhD, Penn Medicine

Joshua Atkins ( is associate professor of Anesthesiology and Critical Care, and director of Anesthesia for Head and Neck Surgery at the Perelman School of Medicine at the University of Pennsylvania. He is co-chair of the Penn Medicine System Airway Safety Committee, serves on the editorial board of Patient Safety, directs the perioperative team simulation program at the Hospital of the University of Pennsylvania, and is a TeamSTEPPS educator. Dr. Atkins is currently partnering with industry on the development of novel technologies for anesthesia medication safety.

Leah Lambe, BSN, RN, Penn Medicine

Leah Lambe is a registered nurse with the Hospital of the University of Pennsylvania. Her clinical expertise involves roles as an emergency department/trauma nurse, nurse clinical coordinator, and interdisciplinary patient safety officer (IPSO). She received her undergraduate degree from the University of Pittsburgh School of Nursing (2005) and is currently pursuing her Master of Science in nursing and Master of Business Administration from the University of Texas at Tyler (2024). As nurse clinical coordinator, she is responsible for co-leading clinical emergencies with advanced providers and/or physicians within the hospital and outpatient settings. In her IPSO role, she reviews, deems, and tracks safety events or risks of safety events. In 2018 she joined the Penn Airway Safety Committee and has done work to bring airway standardization and safety to the forefront at the hospital and the health system.

Laura Marchiano, BS, RRT, Penn Medicine

Laura Marchiano is a respiratory therapist at the Hospital of the University of Pennsylvania. She received her bachelor’s degree from Widener University and is currently pursuing her master’s in allied health education there as well (2024). In 2019 Marchiano started her dual role as tracheostomy coordinator and home ventilation specialist. She is a part of the Penn Airway Safety Committee, organizes tracheostomy rounds, and has a leadership role in the health system’s tracheostomy collaborative.

Lea Anne Gardner, PhD, RN, Patient Safety Authority

Lea Anne Gardner is a patient safety analyst with the Patient Safety Authority. She has more than 30 years of research experience in patient safety, performance improvement, cardiology, and behavioral health. She has served as a national director of nursing, quality improvement, and population health, and as an administrative director of an institutional review board. Gardner is also a Certified Professional in Patient Safety (CPPS).

Doreen Lam, BA, Penn Medicine

Doreen Lam is a third-year medical student at the Perelman School of Medicine at the University of Pennsylvania. She has a professional background as a product manager developing quality improvement software. Most recently, she was an innovation fellow at Penn Medicine’s Center for Health Care Innovation, designing health system solutions to improve patient care during the COVID-19 pandemic.

Christopher H. Rassekh, MD, Penn Medicine

Christopher Rassekh is a professor of clinical otorhinolaryngology: head and neck surgery at the Hospital of the University of Pennsylvania. He is a head and neck surgical oncologist and is a co-chair of the Penn Airway Safety committee. He is also director of Risk Reduction and director of Professional Practice at the Department of Otorhinolaryngology — Head and Neck Surgery, and director of the Penn Medicine Salivary Gland Center.


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8 doctors looking at data on the screens of a laptop and mobile phone.



How to Cite

Atkins, J., Lambe, L., Marchiano, L., Gardner, L. A., Lam, D., & Rassekh, C. H. (2022). System-Based Multidisciplinary Initiatives for Improvement in Tracheostomy Care and Safety: Experience of an Academic Health Institution Hospital Network. Patient Safety, 4(1), 40–48.



Patient Safety Initiatives
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