Risk Factors Associated with Readmission and Mortality Among Children Requiring Long-term Mechanical Ventilation: A Systematic Review Protocol

Risk Factors Associated with Readmission and Mortality Among Children Requiring Long-term Mechanical Ventilation: A Systematic Review Protocol | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Study protocol Risk Factors Associated with Readmission and Mortality Among Children Requiring Long-term Mechanical Ventilation: A Systematic Review Protocol Lindsey Scheller, Sandra Staveski, Karley Mariano, Sandra Weiss, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3854680/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : With advancements in technology and clinical care, the number of children receiving long-term mechanical ventilation (LTMV) in their homes is rapidly growing worldwide. Home environments provide children on LTMV with a better quality of life, psychosocial development, autonomy, and fewer infections. However, unexpected hospital readmission and death are significant concerns despite home care benefits. Risk factors associated with readmission and mortality have not been fully examined in existing systematic reviews. This systematic review aims to examine modifiable and non-modifiable risk factors associated with readmission and mortality in infants, children, and adolescents on LTMV. Methods : This systematic review will use the PRISMA P 2015 guidelines.The literature search will include five electronic databases (PubMed, CINAHL, Web of Science, Embase, and Epistemonikos). All quantitative study designs examining risk factors associated with readmission and/or mortality in pediatric patients less than 21 years of age on LTMV will be included. Articles will be limited to peer-reviewed journals and the English language. Covidence software will be used for data management, study screening, and data extraction. The Joanna Briggs Institute critical appraisal tools will be used to assess risk bias in individual studies. The results of a narrative synthesis will be presented in tables and text descriptions. Discussion : This systematic review, to our knowledge, is the first synthesis of risk factors associated with readmission and mortality among children on LTMV. We use systematic review methodology to decrease risk of bias and increase reproducibility. Findings from this review will provide insight into health outcomes after discharge and identify knowledge gaps in current research. Examining risk factors can shape clinical and policy work to identify and support patients and their families with unique and complex clinical, social, and healthcare needs. Establishing such support can reduce hospitalizations and helps ensure children on LTMV can continue to grow healthy in the home environment with families. Systematic review registration : International Prospective Register of Systematic Reviews (PROSPERO): CRD42024492773. Mechanical ventilation Long-term mechanical ventilation Children Readmission Hospitalization Mortality Systematic review Introduction Background and Prevalence An estimated 3,000 to 5,000 infants, children, and adolescents are dependent on long-term invasive mechanical ventilation (LTMV) in the United States ( 1 ). Advancements in technology and clinical care have enabled children, who previously relied on prolonged hospitalizations and long-term care facilities for support, to now receive mechanical ventilation in the comfort of their homes. Compared to the hospital, home environments provide children on LTMV with a better quality of life, psychosocial and educational development, functional and developmental progress, family and patient autonomy, and fewer infections ( 2 – 5 ). LTMV care in the home environment is the most cost-effective setting compared to hospitals or long-term care facilities ( 6 ). During the last two decades, developed countries have reported an increase in home mechanical ventilation prevalence ranging from 0.2 to 6.7 per 100,000 children ( 7 – 10 ). With a rise in children on LTMV receiving care at home, ensuring optimal health outcomes after discharge is important. LTMV is defined as failure to wean from ventilator support 3 months after ventilator initiation and continued ventilator support via tracheostomy for all or part of a 24-hour day ( 11 , 12 ). Caregivers, including parents or other family members trained on airway and respiratory management, may care for their children on LTMV at home if the child is medically stable. However, caring for children at home with medically complex care needs and technology dependence poses challenges and places strain on caregivers. Caregivers must have sufficient knoweldge of ventilator settings and modes, ventilator parameters, emergency care, and general assessment skills. When transitioning to the home setting after discharge, caregivers report stress from assuming full responsibilities of care, lack of safety that was provided from the hospital setting, and uncertainty about their abilities to adapt to these new responsibilities ( 13 , 14 ). Furthermore, caregivers who report higher strain and lower mental health-related quality of life are more likely to have lower confidence in avoiding hospitalization for the child ( 15 ). This vulnerable transitional period may strain caregivers and increase the risk of readmission or other poor health outcomes for children on LTMV. Readmission and mortality In the United States, readmission rates for children on LTMV have been reported to range from 40–59% ( 16 – 19 ). Readmission to the hospital following a previous hospital admission is a measured quality metric of care received in the hospital and may also indicate challenges in managing the child’s health post-discharge in the home or community setting ( 20 ). Readmission to the hospital decreases quality of life, disrupts the child’s daily life and development, and places strain on family functioning and finances ( 21 – 24 ). Risk of mortality also increases with readmission. One cohort study reported a 10% greater chance of death among mechanically ventilated children who were readmitted after discharge ( 25 ). Mortality rates among children on LTMV after discharge are as high as 57% ( 26 ). One systematic review reported a 21% (IQR 15.5–33.5%) median proportion of mortality across 42 studies among children on non-invasive and invasive mechanical ventilation ( 26 ). Previous studies have suggested that underlying diseases are the primary cause of mortality; however, recent studies have indicated that unanticipated deaths are also a major cause ( 26 , 27 ). This suggests that the primary cause of death is not solely attributed to underlying disease progression. Instead, attention should be directed towards modifiable factors, such as the quality of care provided at home or during follow-up, as key considerations in addressing mortality. In addition, proportions of mortality and unanticipated death rates have not changed significantly over the past decades ( 26 , 28 ). With little improvement in readmission and mortality rates, identifying and understanding risk factors associated with readmission and mortality is important to prevent such poor health outcomes. Knowledge gaps Systematic reviews examining the association between risk factors and health outcomes among children on LTMV have been limited to quality of life, ventilator liberation, and mortality. Several systematic reviews on quality of life summarized qualitative data to identify barriers and facilitators to improve quality of life among children on LTMV ( 13 , 29 ). Discharge coordination, communication, adapting to new roles and responsibilities, and support and resources were subjectively identified as barriers. One systematic review that examined mortality and ventilator liberation health outcomes reported higher mortality among invasive (21%) compared to non-invasive (11%) mechanical ventilation ( 26 ). However, discussion on risk factors associated with mortality or liberation were minimal and primarily focused on underlying diagnoses such as central hypoventilation, cardiac disease, and pulmonary disease or airway abnormalities as risk factors ( 26 ). Other risk factors of mortality or liberation were limited to non-modifiable risk factors including age, type of non-invasive ventilation (e.g., continuous positive airway pressure), ventilator modality, and age of ventilator initiation. Two systematic reviews and one integrative review examining risk factors associated with hospital readmissions or repeat emergency department visits were limited to the general pediatric population or the broader medically complex population. Risk factors commonly identified to be associated with readmission included neurologic disorders, technology dependence, insurance type, race/ethnicity, poor medication management, comorbidities, age, and lack of follow-up after discharge. In summary, a significant proportion of the existing published reviews have primarily focused on non-modifiable risk factors or limited their scope to encompass only the general medically complex population or non-invasive mechanical ventilation cohorts, despite children on invasive LTMV being higher-risk ( 30 , 31 ). Therefore, no reviews have examined non-modifiable risk factors (e.g., age, gender, race/ethnicity) specifically among the invasive LTMV population. Moreover, no review has been published on modifiable risk factors (e.g., access to healthcare, caregiver psychosocial support, home nursing) that could be used for intervention development to provide support in the home setting. Despite published studies, risk factors associated with readmission or other health outcomes among children on LTMV via tracheostomy have not been fully examined in a systematic review. Investigation of modifiable and non-modifiable risk factors will help clinicians and researchers identify groups with different clinical and social needs. Establishing known risk factors will enable tailored interventions across care levels, including inpatient care, discharge planning, and the community and home setting. Furthermore, a clear understanding of risk factors is important to health care providers, children, and their families to ensure successful transition to the home setting and to mitigate poor health outcomes. To address this knowledge gap, this systematic review aims to examine modifiable and non-modifiable risk factors associated with hospital readmissions among infants, children, and adolescents who are on long-term invasive mechanical ventilation. Methods This systematic review protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO): registration number CRD42024492773. The preparation of this protocol was guided by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement and Checklist. The 17-item PRISMA-P checklist and the the PRISMA-P statement provide guidelines for quality systematic review protocol development ( 32 , 33 ). Ongoing or completed systematic reviews have been searched for through PROSPERO to ensure this systematic review is not duplicated. Eligibility criteria Table 1 shows the eligibility criteria for studies. Studies examining risk factors associated with readmission and/or mortality in pediatric patients less than 21 years of age who are on LTMV will be included in the systematic review. Descriptive studies with readmission and/or mortality and no association with risk factors will also be included. The age range (birth to 21 years) for pediatric patients in this review is defined by the American Academy of Pediatrics ( 34 ). For this systematic review, LTMV is defined by the American Thoracic Society and Thoracic Society of Australia and New Zealand/Australian Sleep Association as infants, children, or adolescents with special healthcare needs who failed to wean from ventilator support 3 months after ventilator initiation and are medically stable at home with invasive ventilation via tracheostomy for all or part of a 24 hour day ( 11 , 12 ). Pediatric patients who are cared for either in the home setting or in long-term care facilities will be included for the purpose of examining discharge disposition as a potential risk factor for readmission. For the primary outcome of interest, readmission, study settings will be restricted to hospital readmissions. For the secondary outcome of mortality, we will exclude deaths occurring during the index hospitalization (i.e., hospitalization for tracheotomy/ventilator initiation) to specifically capture post-discharge mortality data. The exposure or phenomenon of interest is modifiable and non-modifiable risk factors that increase the risk of specific health outcomes. Non-modifiable risk factors are defined as characteristics or conditions of an individual that cannot be easily altered or influenced through behavioral changes or medical interventions. Modifiable risk factors are conditions, lifestyles, environments, or behaviors of an individual that can be altered or influenced to mitigate the risk of a particular health outcome. We will include studies from peer-reviewed journals that have quantitative study designs. Qualitative studies will be excluded due to the nature of our outcome of interest and the existence of a preexisting systematic review that has already examined qualitative evidence. There will be no restriction on geographical location of study to ensure a comprehensive and global review of this small population. Year of publication will not be restricted because home ventilation is a fairly new and emerging population with the first home ventilator program beginning In the late 1970s at Children’s Hospital of Pennsylvania ( 1 ). Table 1 Table of Eligibility Criteria Inclusion Criteria Exclusion Criteria Sample • Pediatric patients less than 21 years of age with advanced airways and long-term home invasive mechanical ventilation • Reside at home or in an outpatient long-term care facility at time of outcome occurrence (i.e., time of readmission or mortality) • Pediatric patients only on non-invasive ventilation • Pediatric patients only with advanced airways and no ventilator Phenomenon of Interest • Non-modifiable risk factors (e.g., age, gender, geographical location, age of tracheotomy/ventilator) • Modifiable risk factors (e.g., healthcare access and quality, psychosocial support, social services, home nursing) • None Design • Randomized controlled trials, quasi-experimental studies, cohort studies, cross-sectional studies, case-control studies • Studies reporting only qualitative data • Case studies Evaluation (Primary) • Readmission (planned and/or unplanned) • Readmission for elective surgeries (e.g., g-tube insertion) Evaluation (Secondary) • Mortality • In-hospital mortality during index hospitalization Report Characteristics • Peer-reviewed journal articles • Full-text available in English • Systematic reviews, other reviews, protocols, editorials, dissertations or conference abstracts Information sources and search strategy Five electronic databases, PubMed, CINAHL (EBSCOhost), Web of Science, Embase, and Epistemonikos, will be used to search for studies. A systematic search strategy with medical subject headings (MeSH) and keywords related to long-term mechanical ventilation was developed with a medical librarian (LC) to identify studies. A sample of the PubMed search strategies is provided in Appendix 1. Appendix 1. Sample Search Strategies for PubMed Search PubMed query #1 Sample infant [mh] OR baby OR neonat* OR infant, newborn[mh] OR child*[mh] OR children OR child, preschool[mh] OR adolesc*[mh] OR teen* OR minor* OR “young adult*” OR pediatric OR paediatric #2 Sample "respiration, artificial"[mh] OR "respiration, artificial" OR ventilat* OR ventilators, mechanical [mh] OR "mechanical ventilation" OR "invasive ventilation" OR "home mechanical ventilation" OR respiratory insufficiency[mh] OR respiratory artificial OR tracheostom*[mh] OR tracheotomy OR ventilat* dependen* OR "technology dependen*" OR "chronic ventilat*" OR “long-term mechanical ventilation” OR “long term ventilation” OR “respiratory support” OR “medical* complex*” OR “medically fragile” OR “chronic disease” OR “complex care” OR “complex need” OR “complex healthcare needs” OR “special healthcare needs” OR “special need” OR CYSHCN OR “children/youth with special health care needs” #3 Sample home* OR “home care” OR “home nursing” [mh] OR "home care services"[mh] OR “home health services” OR "home health aides"[mh] OR "nursing homes"[mh] OR "long term care"[mh] OR “long-term care” OR “medical home” #6 Outcome (Evaluation) readmission OR “patient readmission” OR rehospitalization* OR “unplanned readmission” OR “unplanned hospital readmission” OR “thirty day readmission” OR “30 day readmission” OR “hospital readmission” OR readmittance OR “preventable hospitalization” OR “hospital resource use” OR “health care utilization” OR “emergency room visit” OR “emergency department visit” OR mortality [mh] OR mortality [tiab] OR “child mortality” OR death #7 Search #1 AND #2 AND #3 AND #6 Hand searching and citation chaining will be used to identify additional studies. Reference lists of eligible articles will be searched, and studies that have subsequently cited key studies will be identified using Web of Science. In addition, nationally recognized experts in pediatric pulmonary diseases will be identified and contacted by the project team to consult and ensure key literature on the topic has been included. The search strategies for each database will be updated toward the end of the review to ensure that the maximum number of eligible studies are found. Data management and study selection Articles identified through the literature search will first be downloaded and managed on Zotero, a reference software program. Duplicates of studies will be removed through Zotero. The remaining articles will then be imported and organized in Covidence, a web-based software platform that manages data and facilitates collaboration among reviewers during screening, full-text review, and data extraction. Once references are uploaded into Covidence, the remaining duplicates of studies will be removed. Training of the two reviewers (LS, KM) and calibration exercises will be conducted on 3–5% of potential articles before starting the title/abstract and full-text screening to ensure consistency across reviewers and to ensure relevant data are captured appropriately. Using Covidence, two reviewers (LS, KM) will independently screen titles and abstracts from the search based on the eligibility criteria (Table 1 ). If the titles and abstracts meet the eligibility criteria, full-text reports will be obtained and reviewed independently and in duplicate by the two reviewers to identify relevant studies for final inclusion. Reasons for excluding studies will be noted in Covidence. Disagreement regarding the eligibility of the study between the two reviewers will be resolved through discussion and a third reviewer (YF). Study authors will be contacted if additional information is needed to ensure the eligibility of individual studies. Inter-rater agreement will be calculated and reported as Cohen’s Kappa and percent agreement ( 35 ). The results of the selection process will be illustrated using the 2020 PRISMA flow diagram ( 36 ). Data extraction and standardization Data will be extracted in Covidence using standardized Covidence extraction forms customized for this review. Data extraction forms in Covidence will be piloted for each study design type before final data extraction. One reviewer (LS) will extract data from the eligible studies and a second reviewer (KM) will check accuracy and consistency of extracted data. Disagreements during data extraction will be resolved through discussion and a third reviewer (YF) ( 37 ). Data items to be extracted include but are not limited to: 1) study characteristics: first author, publication year, country, methodology (i.e., study design, eligibility criteria, recruitment, length of follow-up), setting (i.e., rural, urban, hospital, emergency department), primary aims, results, limitations, theoretical frameworks used, and funding sources; 2) Participant characteristics: demographics (i.e., gender, race, age), sample size, type and mean length of ventilation, and diagnosis; 3) Exposure: modifiable and non-modifiable risk factors; 4) Outcome: readmission information (i.e., time to readmission, reasons for readmission, readmission rate), mortality information (i.e., mortality rates, time to mortality, reasons for mortality), and definitions/descriptions of study outcomes. 5) Bias assessment data: information relevant to completing bias assessment tools (i.e., Joanna Briggs Institute critical appraisal tools). If additional information is needed from individual studies, authors will be contacted via email a maximum of three times to obtain additional data. Outcomes and Prioritization Primary outcome The primary outcome of interest for this systematic review is hospital readmission, defined as an event when a child recently discharged from a hospital is readmitted within a specific time frame from that initial hospital admission ( 20 ). The readmission time frame is the number of days between discharge from initial hospital admission and admission for a subsequent hospitalization. Readmission is the primary outcome because it is used in the literature as a variable to indicate quality of care received inpatient as well as possible barriers to successful transitioning to the home environment post-discharge ( 38 ). Furthermore, readmission is a more objective measure than other quality of care measures or outcome measures on transitioning to the home setting. According to the U.S. Centers for Medicare & Medicaid Services Hospital Readmissions Reduction Program (HRRP), a readmission time frame that warrants concern is within 30 days of discharge ( 39 ). Despite this guideline, many studies on children with LTMV have discrepancies on which readmissions to measure, such as unplanned versus planned readmissions as well as what time frame to evaluate. Time frames for readmission vary from 30 days, 12 months, first two years of life, to specified study periods because it is not clear what time frame post-discharge is highest risk for the child or family caring for the child. To better understand periods of highest risk of readmission, varying time frames of readmission will be included in the systematic review. Unplanned readmissions will be prioritized in this systematic review to capture indicators of poor quality of care from the hospital, caregiver barriers in providing cares at home, or difficulty transitioning home post-discharge. If studies do not clearly define readmission or data is missing, authors of the study will be contacted for further information. Secondary outcome The secondary outcome is mortality defined as death after discharge from initial hospital admission for tracheotomy and LTMV initiation. Death may occur after discharge in the home, skilled nursing facility, or hospital during a readmission. Mortality is an outcome of interest because this patient population is medically fragile and at higher risk of mortality compared to other medically complex or technology-dependent populations ( 26 ). For this review, mortality rates, causes, circumstances, and timing will be evaluated after discharge from initial hospital admission to help us understand if such poor health outcomes are related to quality of care received before discharge, difficulty transitioning to community or home settings, or the natural progression of underlying diseases. Mortality is the secondary instead of the primary outcome measure because such serious events like death are more uncommon than readmission for this patient population and may limit the power of these studies and the results. If studies do not clearly define mortality or data is missing, the authors of the study will be contacted for further information. Critical appraisal of studies To assess the possible risk of bias and methodological quality for each included study, the Joanna Briggs Institute (JBI) critical appraisal tools will be used to assess the quality of all quantitative studies. The JBI critical appraisal tools are a widely used set of checklists that are designed to evaluate bias and quality across different study designs. These checklists have undergone extensive peer review and approval by the JBI Scientific Committee ( 40 ). The JBI checklists include 8 to 13-items and evaluate studies based on the possibility of bias during study design, conduct, and analysis. Overall appraisal of studies and decision to include studies is subjective because each item is rated as “yes”, “no”, “unclear”, or “not applicable”. Therefore, quality and risk of bias will be judged from the extracted information and rated as high, medium, or low risk based on the number of “no” selected per item decided by the project team. Reviewers will be trained to use the JBI critical appraisal tools, and a pilot of assessing quality will be conducted. Two reviewers (LS, KM) will use the scales independently and a third reviewer (YF) will be used as an arbitrator when disagreements arise. Original study investigators will be contacted if further information is needed to decide on the risk of bias and methodological quality. Risk of bias assessments of the individual studies will be summarized and reported in the systematic review. Studies will be included in the systematic review regardless of the quality or risk of bias score due to limited publications on this patient population. Quality of this systematic review will be evaluated and summarized using the PRISMA checklist (see Additional file 1). Data Synthesis A systematic narrative synthesis of the findings will be presented as tables and text descriptions. Tables and text descriptions will include information that synthesizes and summarizes the main findings and characteristics of the included studies. Data to be synthesized includes participant characteristics, study characteristics, modifiable and non-modifiable risk factors, and associated outcome measures. Information presented will be grouped as a primary cluster based on outcomes (e.g., readmission, mortality). Vote counting will be used to calculate the frequency of different types of results to reveal patterns in the included studies. Conceptual maps will provide a visual of the key concepts and relationships ( 41 ). Studies of any level of risk of bias will be included in the qualitative synthesis. We anticipate that a meta-analysis may not be possible to conduct because of heterogeneity. We will consider conducting a meta-analysis if the assumptions of homogeneity, such as the similarity of participants and medical characteristics and hospital readmission and mortality outcome assessments, are satisfied. ( 37 ). Discussion This systematic review describes modifiable and non-modifiable risk factors associated with hospital readmission and/or mortality in children with LTMV. With an increasing pediatric population with complex medical needs and LTMV at home, providing means to successfully care for the child in the home setting is important. It is crucial for clinicians, caregivers, and researchers to understand risk factors associated with poor health outcomes so that groups at highest risk can be identified and appropriate clinical management can be provided to them, as well as social, financial, and educational support at home. Therefore, this systematic review contributes to a gap in evidence by investigating modifiable and non-modifiable risk factors associated with readmission and mortality. A major strength of this systematic review is the use of PRISMA 2020 guidelines to decrease bias and increase the review's quality, transparency, and reproducibility ( 33 ). A thorough investigation of available literature will be achieved by utilizing five databases and search terms that increase the sensitivity of finding relevant studies. Furthermore, piloting the search strategies, hand searching, and searching reference lists of eligible studies will increase the likelihood of reflecting the majority of studies on this topic and the robustness of this review. Multiple independent reviewers during the screening, selection, and data extraction process will reduce potential bias in the systematic review. In addition, assessing the methodological quality of individual studies with multiple reviewers will increase the strength of this review. Finally, by contacting authors to retrieve missing data, information or quantitative data will be clarified, and results of the systematic review will be reflective of accurate and complete findings. Despite the strengths of this review, several limitations need to be acknowledged. This systematic review is restricted to the English language for included studies and may omit key studies written in other languages. In addition, included studies were limited to peer-reviewed journals which may leave out the newest findings from conference abstracts or other unpublished data or grey literature. Abbreviations LTMV: Long-term mechanical ventilation US: United States SDOH: Social determinants of health CYSHCN: Children and youth with special health care needs PROSPERO: Prospective Register of Systemic Reviews PRISMA-P: Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols MeSH: Medical subject headings RCT: Randomized controlled trial PRISMA: Preferred Reporting Items for Systematic Review and Meta-Analysis HRRP: Hospital Readmissions Reduction Program JBI: Joanna Briggs Institute Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable Availability of data and materials Not applicable Competing interests The authors declare that they have no competing interests Funding This project was supported by the University of California San Francisco (UCSF) Graduate Dean’s Health Sciences Fellowship (GDHSF). Open Access publication was made possible through the UCSF Open Access Publishing Funds. The study sponsors had no role in the study design; collection, analysis, or interpretation of data; writing of the report; or submission of the report for publication. Authors’ contributions LS conceived the review, developed and refined search strategies, and composed the initial draft of this review protocol. YF provided expert guidance on systematic review methodology. SS provided expert guidance on clinical and patient population knowledge. LC provided expert guidance and refinement of search strategies across five bibliographic databases. KM, SW, and AA reviewed and edited the final protocol draft. All authors contributed to the editing of protocol drafts and approved the final manuscript. Acknowledgements Not applicable. Authors’ information Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco (UCSF), CA, USA. Department of Physiological Nursing, School of Nursing, UCSF, CA, USA. Institute for Health & Aging, School of Nursing, UCSF, CA, USA. Department of Community Health Systems, School of Nursing, UCSF, CA, USA. References King AC. Long-Term Home Mechanical Ventilation in the United States. Respir Care. 2012;57(6):921–32. Sahetya S, Allgood S, Gay PC, Lechtzin N. Long-Term Mechanical Ventilation. Clin Chest Med. 2016;37(4):753–63. Baldwin-Myers AS, Oppenheimer EA. Quality of life and quality of care data from a 7-year pilot project for home ventilator patients. J Ambul Care Manage. 1996;19(1):46–59. Burr BH, Guyer B, Todres ID, Abrahams B, Chiodo T. 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Long-term Non-Invasive Ventilation in Infants: A Systematic Review and Meta-Analysis. Front Pediatr. 2018;6:13. AlBalawi MM, Castro-Codesal M, Featherstone R, Sebastianski M, Vandermeer B, Alkhaledi B, et al. Outcomes of Long-Term Noninvasive Ventilation Use in Children with Neuromuscular Disease: Systematic Review and Meta-Analysis. Ann Am Thorac Soc. 2022;19(1):109–19. Page MJ, Moher D, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD et al. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ. 2021;n160. Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ. 2015;349:g7647. Hardin AP, Hackell JM, COMMITTEE ON PRACTICE AND AMBULATORY MEDICINE, Simon GR, Boudreau ADA, Baker CN, et al. Age Limit of Pediatrics Pediatrics. 2017;140(3):e20172151. Park CU, Kim HJ. Measurement of Inter-Rater Reliability in Systematic Review. Hanyang Med Rev. 2015;35(1):44–9. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;n71. Boland A. Doing a systematic review. SAGE Publications; 2017. Halfon P, Eggli Y, Prêtre-Rohrbach I, Meylan D, Marazzi A, Burnand B. Validation of the potentially avoidable hospital readmission rate as a routine indicator of the quality of hospital care. Med Care. 2006;44(11):972–81. Centers for Medicare & Medicaid Services. CMS.gov. [cited 2023 Jul 19]. Hospital Readmissions Reduction Program (HRRP). Available from: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/hrrp/hospital-readmission-reduction-program . Barker TH, Stone JC, Sears K, Klugar M, Leonardi-Bee J, Tufanaru C, et al. Revising the JBI quantitative critical appraisal tools to improve their applicability: an overview of methods and the development process. JBI Evid Synth. 2023;21(3):478. Popay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M et al. Guidance on the Conduct of Narrative Synthesis in Systematic Reviews.:92. Giambra BK, Spratling R. Examining Children With Complex Care and Technology Needs in the Context of Social Determinants of Health. J Pediatr Health Care. 2023;37(3):262–8. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3854680","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Study protocol","associatedPublications":[],"authors":[{"id":266854692,"identity":"1552f4df-a63f-42c2-ad6e-fe599049acc4","order_by":0,"name":"Lindsey Scheller","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIie2QMUvDQBiG3xLQ5WrXK1LzF75yEJGU+lciB3EJ1TFDKQHBLqKr/gsn5ysHTueebgXBOWNcrHdaFyHJKnjP9B28D9/7HeDx/EEoALgbwoIBm0tg4F450Cu6FFJWSQgYuqhpU/CjYKeQ6lL2+6t1nWs7vKw2CU0uRClfK4XJ6FE1FTuQMTMa4c1MUkLpyVOZRlwhFc0Kiw571xooWcQT0hSV2V5QQZ+1KcP3jy/luE5oS+I+C2yxbavC+8X3Fnu+IuIZbDHVpoiYPZ8zMpmwxSRx82ZvISkeGpTTOzNe1/P4KFyacVXlUxos3Y/l09Ftg7Ljiv3e3hp3LDoTHo/H84/5BOGzWvljb0zoAAAAAElFTkSuQmCC","orcid":"","institution":"University of California, San Francisco","correspondingAuthor":true,"prefix":"","firstName":"Lindsey","middleName":"","lastName":"Scheller","suffix":""},{"id":266854693,"identity":"7fb8a77e-2931-4f23-a3d4-f0bae96ff44d","order_by":1,"name":"Sandra Staveski","email":"","orcid":"","institution":"University of California, San Francisco","correspondingAuthor":false,"prefix":"","firstName":"Sandra","middleName":"","lastName":"Staveski","suffix":""},{"id":266854694,"identity":"99195a91-44ee-40a3-aa53-d872e1bc1f8c","order_by":2,"name":"Karley Mariano","email":"","orcid":"","institution":"University of California, San Francisco","correspondingAuthor":false,"prefix":"","firstName":"Karley","middleName":"","lastName":"Mariano","suffix":""},{"id":266854695,"identity":"5c691064-977d-4f34-84f0-8208258ed11c","order_by":3,"name":"Sandra Weiss","email":"","orcid":"","institution":"University of California, San Francisco","correspondingAuthor":false,"prefix":"","firstName":"Sandra","middleName":"","lastName":"Weiss","suffix":""},{"id":266854696,"identity":"106b5c4f-0484-4cd6-8662-6ce05e5ea85e","order_by":4,"name":"Abbey Alkon","email":"","orcid":"","institution":"University of California, San Francisco","correspondingAuthor":false,"prefix":"","firstName":"Abbey","middleName":"","lastName":"Alkon","suffix":""},{"id":266854697,"identity":"d33dc861-93ee-4fa4-b429-d5d5326f766a","order_by":5,"name":"Leia Casey","email":"","orcid":"","institution":"University of California, San Francisco","correspondingAuthor":false,"prefix":"","firstName":"Leia","middleName":"","lastName":"Casey","suffix":""},{"id":266854698,"identity":"1a4a32e6-dac3-47ec-a7cd-9b55bad91fe2","order_by":6,"name":"Yoshimi Fukuoka","email":"","orcid":"","institution":"University of California, San Francisco","correspondingAuthor":false,"prefix":"","firstName":"Yoshimi","middleName":"","lastName":"Fukuoka","suffix":""}],"badges":[],"createdAt":"2024-01-11 20:30:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3854680/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3854680/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":50141308,"identity":"2e8032c5-b348-47c1-87e4-ddff40b6b631","added_by":"auto","created_at":"2024-01-25 06:52:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":357861,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3854680/v1/7ebdd981-0f3d-4bb3-8797-ba3b8c07e92b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Risk Factors Associated with Readmission and Mortality Among Children Requiring Long-term Mechanical Ventilation: A Systematic Review Protocol","fulltext":[{"header":"Introduction","content":"\n\u003ch3\u003eBackground and Prevalence\u003c/h3\u003e\n\u003cp\u003eAn estimated 3,000 to 5,000 infants, children, and adolescents are dependent on long-term invasive mechanical ventilation (LTMV) in the United States (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Advancements in technology and clinical care have enabled children, who previously relied on prolonged hospitalizations and long-term care facilities for support, to now receive mechanical ventilation in the comfort of their homes. Compared to the hospital, home environments provide children on LTMV with a better quality of life, psychosocial and educational development, functional and developmental progress, family and patient autonomy, and fewer infections (\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). LTMV care in the home environment is the most cost-effective setting compared to hospitals or long-term care facilities (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). During the last two decades, developed countries have reported an increase in home mechanical ventilation prevalence ranging from 0.2 to 6.7 per 100,000 children (\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). With a rise in children on LTMV receiving care at home, ensuring optimal health outcomes after discharge is important.\u003c/p\u003e \u003cp\u003eLTMV is defined as failure to wean from ventilator support 3 months after ventilator initiation and continued ventilator support via tracheostomy for all or part of a 24-hour day (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Caregivers, including parents or other family members trained on airway and respiratory management, may care for their children on LTMV at home if the child is medically stable. However, caring for children at home with medically complex care needs and technology dependence poses challenges and places strain on caregivers. Caregivers must have sufficient knoweldge of ventilator settings and modes, ventilator parameters, emergency care, and general assessment skills. When transitioning to the home setting after discharge, caregivers report stress from assuming full responsibilities of care, lack of safety that was provided from the hospital setting, and uncertainty about their abilities to adapt to these new responsibilities (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Furthermore, caregivers who report higher strain and lower mental health-related quality of life are more likely to have lower confidence in avoiding hospitalization for the child (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). This vulnerable transitional period may strain caregivers and increase the risk of readmission or other poor health outcomes for children on LTMV.\u003c/p\u003e\n\u003ch3\u003eReadmission and mortality\u003c/h3\u003e\n\u003cp\u003eIn the United States, readmission rates for children on LTMV have been reported to range from 40\u0026ndash;59% (\u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Readmission to the hospital following a previous hospital admission is a measured quality metric of care received in the hospital and may also indicate challenges in managing the child\u0026rsquo;s health post-discharge in the home or community setting (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Readmission to the hospital decreases quality of life, disrupts the child\u0026rsquo;s daily life and development, and places strain on family functioning and finances (\u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Risk of mortality also increases with readmission. One cohort study reported a 10% greater chance of death among mechanically ventilated children who were readmitted after discharge (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMortality rates among children on LTMV after discharge are as high as 57% (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). One systematic review reported a 21% (IQR 15.5\u0026ndash;33.5%) median proportion of mortality across 42 studies among children on non-invasive and invasive mechanical ventilation (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Previous studies have suggested that underlying diseases are the primary cause of mortality; however, recent studies have indicated that unanticipated deaths are also a major cause (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). This suggests that the primary cause of death is not solely attributed to underlying disease progression. Instead, attention should be directed towards modifiable factors, such as the quality of care provided at home or during follow-up, as key considerations in addressing mortality. In addition, proportions of mortality and unanticipated death rates have not changed significantly over the past decades (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). With little improvement in readmission and mortality rates, identifying and understanding risk factors associated with readmission and mortality is important to prevent such poor health outcomes.\u003c/p\u003e\n\u003ch3\u003eKnowledge gaps\u003c/h3\u003e\n\u003cp\u003eSystematic reviews examining the association between risk factors and health outcomes among children on LTMV have been limited to quality of life, ventilator liberation, and mortality. Several systematic reviews on quality of life summarized qualitative data to identify barriers and facilitators to improve quality of life among children on LTMV (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Discharge coordination, communication, adapting to new roles and responsibilities, and support and resources were subjectively identified as barriers. One systematic review that examined mortality and ventilator liberation health outcomes reported higher mortality among invasive (21%) compared to non-invasive (11%) mechanical ventilation (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). However, discussion on risk factors associated with mortality or liberation were minimal and primarily focused on underlying diagnoses such as central hypoventilation, cardiac disease, and pulmonary disease or airway abnormalities as risk factors (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Other risk factors of mortality or liberation were limited to non-modifiable risk factors including age, type of non-invasive ventilation (e.g., continuous positive airway pressure), ventilator modality, and age of ventilator initiation.\u003c/p\u003e \u003cp\u003eTwo systematic reviews and one integrative review examining risk factors associated with hospital readmissions or repeat emergency department visits were limited to the general pediatric population or the broader medically complex population. Risk factors commonly identified to be associated with readmission included neurologic disorders, technology dependence, insurance type, race/ethnicity, poor medication management, comorbidities, age, and lack of follow-up after discharge. In summary, a significant proportion of the existing published reviews have primarily focused on non-modifiable risk factors or limited their scope to encompass only the general medically complex population or non-invasive mechanical ventilation cohorts, despite children on invasive LTMV being higher-risk (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Therefore, no reviews have examined non-modifiable risk factors (e.g., age, gender, race/ethnicity) specifically among the invasive LTMV population. Moreover, no review has been published on modifiable risk factors (e.g., access to healthcare, caregiver psychosocial support, home nursing) that could be used for intervention development to provide support in the home setting.\u003c/p\u003e \u003cp\u003eDespite published studies, risk factors associated with readmission or other health outcomes among children on LTMV via tracheostomy have not been fully examined in a systematic review. Investigation of modifiable and non-modifiable risk factors will help clinicians and researchers identify groups with different clinical and social needs. Establishing known risk factors will enable tailored interventions across care levels, including inpatient care, discharge planning, and the community and home setting. Furthermore, a clear understanding of risk factors is important to health care providers, children, and their families to ensure successful transition to the home setting and to mitigate poor health outcomes. To address this knowledge gap, this systematic review aims to examine modifiable and non-modifiable risk factors associated with hospital readmissions among infants, children, and adolescents who are on long-term invasive mechanical ventilation.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis systematic review protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO): registration number CRD42024492773. The preparation of this protocol was guided by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement and Checklist. The 17-item PRISMA-P checklist and the the PRISMA-P statement provide guidelines for quality systematic review protocol development (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Ongoing or completed systematic reviews have been searched for through PROSPERO to ensure this systematic review is not duplicated.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eEligibility criteria\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the eligibility criteria for studies. Studies examining risk factors associated with readmission and/or mortality in pediatric patients less than 21 years of age who are on LTMV will be included in the systematic review. Descriptive studies with readmission and/or mortality and no association with risk factors will also be included. The age range (birth to 21 years) for pediatric patients in this review is defined by the American Academy of Pediatrics (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). For this systematic review, LTMV is defined by the American Thoracic Society and Thoracic Society of Australia and New Zealand/Australian Sleep Association as infants, children, or adolescents with special healthcare needs who failed to wean from ventilator support 3 months after ventilator initiation and are medically stable at home with invasive ventilation via tracheostomy for all or part of a 24 hour day (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Pediatric patients who are cared for either in the home setting or in long-term care facilities will be included for the purpose of examining discharge disposition as a potential risk factor for readmission. For the primary outcome of interest, readmission, study settings will be restricted to hospital readmissions. For the secondary outcome of mortality, we will exclude deaths occurring during the index hospitalization (i.e., hospitalization for tracheotomy/ventilator initiation) to specifically capture post-discharge mortality data. The exposure or phenomenon of interest is modifiable and non-modifiable risk factors that increase the risk of specific health outcomes. Non-modifiable risk factors are defined as characteristics or conditions of an individual that cannot be easily altered or influenced through behavioral changes or medical interventions. Modifiable risk factors are conditions, lifestyles, environments, or behaviors of an individual that can be altered or influenced to mitigate the risk of a particular health outcome.\u003c/p\u003e \u003cp\u003eWe will include studies from peer-reviewed journals that have quantitative study designs. Qualitative studies will be excluded due to the nature of our outcome of interest and the existence of a preexisting systematic review that has already examined qualitative evidence. There will be no restriction on geographical location of study to ensure a comprehensive and global review of this small population. Year of publication will not be restricted because home ventilation is a fairly new and emerging population with the first home ventilator program beginning In the late 1970s at Children\u0026rsquo;s Hospital of Pennsylvania (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTable of Eligibility Criteria\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInclusion Criteria\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExclusion Criteria\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSample\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Pediatric patients less than 21 years of age with advanced airways and long-term home invasive mechanical ventilation\u003c/p\u003e \u003cp\u003e\u0026bull; Reside at home or in an outpatient long-term care facility at time of outcome occurrence (i.e., time of readmission or mortality)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Pediatric patients only on non-invasive ventilation\u003c/p\u003e \u003cp\u003e\u0026bull; Pediatric patients only with advanced airways and no ventilator\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhenomenon of Interest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Non-modifiable risk factors (e.g., age, gender, geographical location, age of tracheotomy/ventilator)\u003c/p\u003e \u003cp\u003e\u0026bull; Modifiable risk factors (e.g., healthcare access and quality, psychosocial support, social services, home nursing)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; None\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDesign\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Randomized controlled trials, quasi-experimental studies, cohort studies, cross-sectional studies, case-control studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Studies reporting only qualitative data\u003c/p\u003e \u003cp\u003e\u0026bull; Case studies\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvaluation (Primary)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Readmission (planned and/or unplanned)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Readmission for elective surgeries (e.g., g-tube insertion)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvaluation (Secondary)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; In-hospital mortality during index hospitalization\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReport Characteristics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Peer-reviewed journal articles\u003c/p\u003e \u003cp\u003e\u0026bull; Full-text available in English\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Systematic reviews, other reviews, protocols, editorials, dissertations or conference abstracts\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eInformation sources and search strategy\u003c/h2\u003e \u003cp\u003eFive electronic databases, PubMed, CINAHL (EBSCOhost), Web of Science, Embase, and Epistemonikos, will be used to search for studies. A systematic search strategy with medical subject headings (MeSH) and keywords related to long-term mechanical ventilation was developed with a medical librarian (LC) to identify studies. A sample of the PubMed search strategies is provided in Appendix 1.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAppendix 1. Sample Search Strategies for PubMed\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSearch\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePubMed query\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#1 Sample\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003einfant [mh] OR baby OR neonat* OR infant, newborn[mh] OR child*[mh] OR children OR child, preschool[mh] OR adolesc*[mh] OR teen* OR minor* OR \u0026ldquo;young adult*\u0026rdquo; OR pediatric OR paediatric\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#2 Sample\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\"respiration, artificial\"[mh] OR \"respiration, artificial\" OR ventilat* OR ventilators, mechanical [mh] OR \"mechanical ventilation\" OR \"invasive ventilation\" OR \"home mechanical ventilation\" OR respiratory insufficiency[mh] OR respiratory artificial OR tracheostom*[mh] OR tracheotomy OR ventilat* dependen* OR \"technology dependen*\" OR \"chronic ventilat*\" OR \u0026ldquo;long-term mechanical ventilation\u0026rdquo; OR \u0026ldquo;long term ventilation\u0026rdquo; OR \u0026ldquo;respiratory support\u0026rdquo; OR \u0026ldquo;medical* complex*\u0026rdquo; OR \u0026ldquo;medically fragile\u0026rdquo; OR \u0026ldquo;chronic disease\u0026rdquo; OR \u0026ldquo;complex care\u0026rdquo; OR \u0026ldquo;complex need\u0026rdquo; OR \u0026ldquo;complex healthcare needs\u0026rdquo; OR \u0026ldquo;special healthcare needs\u0026rdquo; OR \u0026ldquo;special need\u0026rdquo; OR CYSHCN OR \u0026ldquo;children/youth with special health care needs\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#3 Sample\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ehome* OR \u0026ldquo;home care\u0026rdquo; OR \u0026ldquo;home nursing\u0026rdquo; [mh] OR \"home care services\"[mh] OR \u0026ldquo;home health services\u0026rdquo; OR \"home health aides\"[mh] OR \"nursing homes\"[mh] OR \"long term care\"[mh] OR \u0026ldquo;long-term care\u0026rdquo; OR \u0026ldquo;medical home\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#6 Outcome (Evaluation)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ereadmission OR \u0026ldquo;patient readmission\u0026rdquo; OR rehospitalization* OR \u0026ldquo;unplanned readmission\u0026rdquo; OR \u0026ldquo;unplanned hospital readmission\u0026rdquo; OR \u0026ldquo;thirty day readmission\u0026rdquo; OR \u0026ldquo;30 day readmission\u0026rdquo; OR \u0026ldquo;hospital readmission\u0026rdquo; OR readmittance OR \u0026ldquo;preventable hospitalization\u0026rdquo; OR \u0026ldquo;hospital resource use\u0026rdquo; OR \u0026ldquo;health care utilization\u0026rdquo; OR \u0026ldquo;emergency room visit\u0026rdquo; OR \u0026ldquo;emergency department visit\u0026rdquo; OR mortality [mh] OR mortality [tiab] OR \u0026ldquo;child mortality\u0026rdquo; OR death\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e#7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSearch #1 AND #2 AND #3 AND #6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHand searching and citation chaining will be used to identify additional studies. Reference lists of eligible articles will be searched, and studies that have subsequently cited key studies will be identified using Web of Science. In addition, nationally recognized experts in pediatric pulmonary diseases will be identified and contacted by the project team to consult and ensure key literature on the topic has been included. The search strategies for each database will be updated toward the end of the review to ensure that the maximum number of eligible studies are found.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eData management and study selection\u003c/strong\u003e \u003cp\u003eArticles identified through the literature search will first be downloaded and managed on Zotero, a reference software program. Duplicates of studies will be removed through Zotero. The remaining articles will then be imported and organized in Covidence, a web-based software platform that manages data and facilitates collaboration among reviewers during screening, full-text review, and data extraction. Once references are uploaded into Covidence, the remaining duplicates of studies will be removed. Training of the two reviewers (LS, KM) and calibration exercises will be conducted on 3\u0026ndash;5% of potential articles before starting the title/abstract and full-text screening to ensure consistency across reviewers and to ensure relevant data are captured appropriately.\u003c/p\u003e \u003cp\u003eUsing Covidence, two reviewers (LS, KM) will independently screen titles and abstracts from the search based on the eligibility criteria (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). If the titles and abstracts meet the eligibility criteria, full-text reports will be obtained and reviewed independently and in duplicate by the two reviewers to identify relevant studies for final inclusion. Reasons for excluding studies will be noted in Covidence. Disagreement regarding the eligibility of the study between the two reviewers will be resolved through discussion and a third reviewer (YF). Study authors will be contacted if additional information is needed to ensure the eligibility of individual studies. Inter-rater agreement will be calculated and reported as Cohen\u0026rsquo;s Kappa and percent agreement (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). The results of the selection process will be illustrated using the 2020 PRISMA flow diagram (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eData extraction and standardization\u003c/strong\u003e \u003cp\u003eData will be extracted in Covidence using standardized Covidence extraction forms customized for this review. Data extraction forms in Covidence will be piloted for each study design type before final data extraction. One reviewer (LS) will extract data from the eligible studies and a second reviewer (KM) will check accuracy and consistency of extracted data. Disagreements during data extraction will be resolved through discussion and a third reviewer (YF) (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eData items to be extracted include but are not limited to: 1) study characteristics: first author, publication year, country, methodology (i.e., study design, eligibility criteria, recruitment, length of follow-up), setting (i.e., rural, urban, hospital, emergency department), primary aims, results, limitations, theoretical frameworks used, and funding sources; 2) Participant characteristics: demographics (i.e., gender, race, age), sample size, type and mean length of ventilation, and diagnosis; 3) Exposure: modifiable and non-modifiable risk factors; 4) Outcome: readmission information (i.e., time to readmission, reasons for readmission, readmission rate), mortality information (i.e., mortality rates, time to mortality, reasons for mortality), and definitions/descriptions of study outcomes. 5) Bias assessment data: information relevant to completing bias assessment tools (i.e., Joanna Briggs Institute critical appraisal tools). If additional information is needed from individual studies, authors will be contacted via email a maximum of three times to obtain additional data.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eOutcomes and Prioritization\u003c/strong\u003e \u003cp\u003e \u003cem\u003ePrimary outcome\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe primary outcome of interest for this systematic review is hospital readmission, defined as an event when a child recently discharged from a hospital is readmitted within a specific time frame from that initial hospital admission (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The readmission time frame is the number of days between discharge from initial hospital admission and admission for a subsequent hospitalization. Readmission is the primary outcome because it is used in the literature as a variable to indicate quality of care received inpatient as well as possible barriers to successful transitioning to the home environment post-discharge (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Furthermore, readmission is a more objective measure than other quality of care measures or outcome measures on transitioning to the home setting.\u003c/p\u003e \u003cp\u003eAccording to the U.S. Centers for Medicare \u0026amp; Medicaid Services Hospital Readmissions Reduction Program (HRRP), a readmission time frame that warrants concern is within 30 days of discharge (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Despite this guideline, many studies on children with LTMV have discrepancies on which readmissions to measure, such as unplanned versus planned readmissions as well as what time frame to evaluate. Time frames for readmission vary from 30 days, 12 months, first two years of life, to specified study periods because it is not clear what time frame post-discharge is highest risk for the child or family caring for the child. To better understand periods of highest risk of readmission, varying time frames of readmission will be included in the systematic review. Unplanned readmissions will be prioritized in this systematic review to capture indicators of poor quality of care from the hospital, caregiver barriers in providing cares at home, or difficulty transitioning home post-discharge. If studies do not clearly define readmission or data is missing, authors of the study will be contacted for further information.\u003c/p\u003e \u003cp\u003e \u003cem\u003eSecondary outcome\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe secondary outcome is mortality defined as death after discharge from initial hospital admission for tracheotomy and LTMV initiation. Death may occur after discharge in the home, skilled nursing facility, or hospital during a readmission. Mortality is an outcome of interest because this patient population is medically fragile and at higher risk of mortality compared to other medically complex or technology-dependent populations (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). For this review, mortality rates, causes, circumstances, and timing will be evaluated after discharge from initial hospital admission to help us understand if such poor health outcomes are related to quality of care received before discharge, difficulty transitioning to community or home settings, or the natural progression of underlying diseases. Mortality is the secondary instead of the primary outcome measure because such serious events like death are more uncommon than readmission for this patient population and may limit the power of these studies and the results. If studies do not clearly define mortality or data is missing, the authors of the study will be contacted for further information.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCritical appraisal of studies\u003c/strong\u003e \u003cp\u003eTo assess the possible risk of bias and methodological quality for each included study, the Joanna Briggs Institute (JBI) critical appraisal tools will be used to assess the quality of all quantitative studies. The JBI critical appraisal tools are a widely used set of checklists that are designed to evaluate bias and quality across different study designs. These checklists have undergone extensive peer review and approval by the JBI Scientific Committee (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). The JBI checklists include 8 to 13-items and evaluate studies based on the possibility of bias during study design, conduct, and analysis. Overall appraisal of studies and decision to include studies is subjective because each item is rated as \u0026ldquo;yes\u0026rdquo;, \u0026ldquo;no\u0026rdquo;, \u0026ldquo;unclear\u0026rdquo;, or \u0026ldquo;not applicable\u0026rdquo;. Therefore, quality and risk of bias will be judged from the extracted information and rated as high, medium, or low risk based on the number of \u0026ldquo;no\u0026rdquo; selected per item decided by the project team.\u003c/p\u003e \u003cp\u003eReviewers will be trained to use the JBI critical appraisal tools, and a pilot of assessing quality will be conducted. Two reviewers (LS, KM) will use the scales independently and a third reviewer (YF) will be used as an arbitrator when disagreements arise. Original study investigators will be contacted if further information is needed to decide on the risk of bias and methodological quality. Risk of bias assessments of the individual studies will be summarized and reported in the systematic review. Studies will be included in the systematic review regardless of the quality or risk of bias score due to limited publications on this patient population. Quality of this systematic review will be evaluated and summarized using the PRISMA checklist (see Additional file 1).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eData Synthesis\u003c/strong\u003e \u003cp\u003eA systematic narrative synthesis of the findings will be presented as tables and text descriptions. Tables and text descriptions will include information that synthesizes and summarizes the main findings and characteristics of the included studies. Data to be synthesized includes participant characteristics, study characteristics, modifiable and non-modifiable risk factors, and associated outcome measures. Information presented will be grouped as a primary cluster based on outcomes (e.g., readmission, mortality). Vote counting will be used to calculate the frequency of different types of results to reveal patterns in the included studies. Conceptual maps will provide a visual of the key concepts and relationships (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Studies of any level of risk of bias will be included in the qualitative synthesis.\u003c/p\u003e \u003cp\u003eWe anticipate that a meta-analysis may not be possible to conduct because of heterogeneity. We will consider conducting a meta-analysis if the assumptions of homogeneity, such as the similarity of participants and medical characteristics and hospital readmission and mortality outcome assessments, are satisfied.\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e "},{"header":"Discussion","content":"\u003cp\u003eThis systematic review describes modifiable and non-modifiable risk factors associated with hospital readmission and/or mortality in children with LTMV. With an increasing pediatric population with complex medical needs and LTMV at home, providing means to successfully care for the child in the home setting is important. It is crucial for clinicians, caregivers, and researchers to understand risk factors associated with poor health outcomes so that groups at highest risk can be identified and appropriate clinical management can be provided to them, as well as social, financial, and educational support at home. Therefore, this systematic review contributes to a gap in evidence by investigating modifiable and non-modifiable risk factors associated with readmission and mortality.\u003c/p\u003e \u003cp\u003eA major strength of this systematic review is the use of PRISMA 2020 guidelines to decrease bias and increase the review's quality, transparency, and reproducibility (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). A thorough investigation of available literature will be achieved by utilizing five databases and search terms that increase the sensitivity of finding relevant studies. Furthermore, piloting the search strategies, hand searching, and searching reference lists of eligible studies will increase the likelihood of reflecting the majority of studies on this topic and the robustness of this review. Multiple independent reviewers during the screening, selection, and data extraction process will reduce potential bias in the systematic review. In addition, assessing the methodological quality of individual studies with multiple reviewers will increase the strength of this review. Finally, by contacting authors to retrieve missing data, information or quantitative data will be clarified, and results of the systematic review will be reflective of accurate and complete findings.\u003c/p\u003e \u003cp\u003eDespite the strengths of this review, several limitations need to be acknowledged. This systematic review is restricted to the English language for included studies and may omit key studies written in other languages. In addition, included studies were limited to peer-reviewed journals which may leave out the newest findings from conference abstracts or other unpublished data or grey literature.\u003c/p\u003e \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eLTMV: Long-term mechanical ventilation\u003c/p\u003e\n\u003cp\u003eUS: United States\u003c/p\u003e\n\u003cp\u003eSDOH: Social determinants of health\u003c/p\u003e\n\u003cp\u003eCYSHCN: Children and youth with special health care needs\u003c/p\u003e\n\u003cp\u003ePROSPERO: Prospective Register of Systemic Reviews\u003c/p\u003e\n\u003cp\u003ePRISMA-P: Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols\u003c/p\u003e\n\u003cp\u003eMeSH: Medical subject headings\u003c/p\u003e\n\u003cp\u003eRCT: Randomized controlled trial\u003c/p\u003e\n\u003cp\u003ePRISMA: Preferred Reporting Items for Systematic Review and Meta-Analysis\u003c/p\u003e\n\u003cp\u003eHRRP: Hospital Readmissions Reduction Program\u003c/p\u003e\n\u003cp\u003eJBI: Joanna Briggs Institute\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project was supported by the University of California San Francisco (UCSF) Graduate Dean\u0026rsquo;s Health Sciences Fellowship (GDHSF). Open Access publication was made possible through the UCSF Open Access Publishing Funds. The study sponsors had no role in the study design; collection, analysis, or interpretation of data; writing of the report; or submission of the report for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLS conceived the review, developed and refined search strategies, and composed the initial draft of this review protocol. YF provided expert guidance on systematic review methodology. SS provided expert guidance on clinical and patient population knowledge. LC provided expert guidance and refinement of search strategies across five bibliographic databases. KM, SW, and AA reviewed and edited the final protocol draft. All authors contributed to the editing of protocol drafts and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDepartment of Family Health Care Nursing, School of Nursing, University of California, San Francisco (UCSF), CA, USA. Department of Physiological Nursing, School of Nursing, UCSF, CA, USA. Institute for Health \u0026amp; Aging, School of Nursing, UCSF, CA, USA. Department of Community Health Systems, School of Nursing, UCSF, CA, USA.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKing AC. Long-Term Home Mechanical Ventilation in the United States. Respir Care. 2012;57(6):921\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSahetya S, Allgood S, Gay PC, Lechtzin N. Long-Term Mechanical Ventilation. Clin Chest Med. 2016;37(4):753\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaldwin-Myers AS, Oppenheimer EA. Quality of life and quality of care data from a 7-year pilot project for home ventilator patients. J Ambul Care Manage. 1996;19(1):46\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurr BH, Guyer B, Todres ID, Abrahams B, Chiodo T. Home Care for Children on Respirators. N Engl J Med. 1983;309(21):1319\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAday LA, Wegener DH, Andersen RM, Aitken MJ. Home Care For Ventilator-Assisted Children. Health Aff (Millwood). 1989;8(2):137\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFields AI, Rosenblatt A, Pollack MM, Kaufman J. Home care cost-effectiveness for respiratory technology-dependent children. 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J Sch Psychol. 1998;36:261\u0026ndash;79.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBorges EF, Borges-J\u0026uacute;nior LH, Carvalho AJL, Ferreira HM, Hattori WT. Azevedo VMG de O. Invasive Home Mechanical Ventilation: 10-Year Experience of a Pediatric Home Care Service. Respir Care. 2020;65(12):1800\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFoy CM, Koncicki ML, Edwards JD. Liberation and mortality outcomes in pediatric long-term ventilation: A qualitative systematic review. Pediatr Pulmonol. 2020;55(11):2853\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEdwards JD, Kun SS, Keens TG. Outcomes and causes of death in children on home mechanical ventilation via tracheostomy: an institutional and literature review. J Pediatr. 2010;157(6):955\u0026ndash;959e2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoroughs D, Dougherty JA. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/hrrp/hospital-readmission-reduction-program\u003c/span\u003e\u003cspan address=\"https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/hrrp/hospital-readmission-reduction-program\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarker TH, Stone JC, Sears K, Klugar M, Leonardi-Bee J, Tufanaru C, et al. Revising the JBI quantitative critical appraisal tools to improve their applicability: an overview of methods and the development process. JBI Evid Synth. 2023;21(3):478.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePopay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M et al. Guidance on the Conduct of Narrative Synthesis in Systematic Reviews.:92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGiambra BK, Spratling R. Examining Children With Complex Care and Technology Needs in the Context of Social Determinants of Health. J Pediatr Health Care. 2023;37(3):262\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Mechanical ventilation, Long-term mechanical ventilation, Children, Readmission, Hospitalization, Mortality, Systematic review","lastPublishedDoi":"10.21203/rs.3.rs-3854680/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3854680/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: With advancements in technology and clinical care, the number of children receiving long-term mechanical ventilation (LTMV) in their homes is rapidly growing worldwide. Home environments provide children on LTMV with a better quality of life, psychosocial development, autonomy, and fewer infections. However, unexpected hospital readmission and death are significant concerns despite home care benefits. Risk factors associated with readmission and mortality have not been fully examined in existing systematic reviews. This systematic review aims to examine modifiable and non-modifiable risk factors associated with readmission and mortality in infants, children, and adolescents on LTMV.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: This systematic review will use the PRISMA P 2015 guidelines.The literature search will include five electronic databases (PubMed, CINAHL, Web of Science, Embase, and Epistemonikos). All quantitative study designs examining risk factors associated with readmission and/or mortality in pediatric patients less than 21 years of age on LTMV will be included. Articles will be limited to peer-reviewed journals and the English language. Covidence software will be used for data management, study screening, and data extraction. The Joanna Briggs Institute critical appraisal tools will be used to assess risk bias in individual studies. The results of a narrative synthesis will be presented in tables and text descriptions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e: This systematic review, to our knowledge, is the first synthesis of risk factors associated with readmission and mortality among children on LTMV. We use systematic review methodology to decrease risk of bias and increase reproducibility. Findings from this review will provide insight into health outcomes after discharge and identify knowledge gaps in current research. Examining risk factors can shape clinical and policy work to identify and support patients and their families with unique and complex clinical, social, and healthcare needs. Establishing such support can reduce hospitalizations and helps ensure children on LTMV can continue to grow healthy in the home environment with families.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSystematic review registration\u003c/strong\u003e: International Prospective Register of Systematic Reviews (PROSPERO): CRD42024492773.\u003c/p\u003e","manuscriptTitle":"Risk Factors Associated with Readmission and Mortality Among Children Requiring Long-term Mechanical Ventilation: A Systematic Review Protocol","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-16 09:54:58","doi":"10.21203/rs.3.rs-3854680/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"58a7096e-6daf-43e9-aaf2-d78c68c56275","owner":[],"postedDate":"January 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-01-25T06:44:19+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-16 09:54:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3854680","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3854680","identity":"rs-3854680","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}