PONE-D-21-09113

Impact of implementation of the national institute for health and clinical excellence (NICE) head injury guideline in a tertiary care center emergency department: A pre and post-intervention study.

PLOS ONE

Dear Dr. Pradhan,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Both reviewers show support for this manuscript although one reviewer has raised concerns about the presentation of the data that will need to be addressed in a revised version.  Additionally, one reviewer also raises the limitations of before and after studies and this is an important point.  The manuscript should include acknowledgement of the challenges and limitations of before and after studies, and the potential for bias in the findings. Discussion of why an RCT was not performed, and justification for the before and after approach would be beneficial.

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Belinda J Gabbe, PhD

Academic Editor

PLOS ONE

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3. Please provide the date range of the pre-implementation and post-implementation periods.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I would like to thank the authors for this study which looked at the impact of NICE guidelines on head injuries using a pre and post intervention analysis. A significant decrease in the number of CT and a significant guideline adherence were observed post implementation. It is well known that pre-post study designs can lead to erroneous results in the absence of a control group. This is my main concern in regards to this study.

I have some comments :

- lines 259, 260 and 342 the difference in percentage is not expressed as percentage but in number of percentage point.

Instead of "..decreased by 20.3% ....... increased by 20.3% ..." should read " "..decreased by 20.3 percentage points ....... increased by 20.3 per. For rate of increase use (new-old)/old*100.

-Line 333 : Even in the reference [27] they made the same mistake.

-Table 3: Some miscalculations in Table 3:

For Clinical judgement For NICE

PPV 46.3% (82.4% - 100%) PPV 69% (52.9% - 82.4%)

NPV 100% (82.4% 0 100%) NPV 95.5% (84.5% - 99.4%)

Acc 58.1% (47.7% - 68.5%) Acc 82.6% (74.6% - 90.6%)

Reviewer #2: Thank you for submitting this paper for publication. Although the numbers of patients with head injury are low, the results of the study are significant in that the introduction of the NICE Head Injury Guidelines resulted in more appropriate ordering of CT Brain scans in patients with head injuries.

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Reviewer #1: No

Reviewer #2: No

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Impact of implementation of the national institute for health and clinical excellence (NICE) head injury guideline in a tertiary care center emergency department: A pre and post-intervention study.

PONE-D-21-09113R1

Dear Dr. Pradhan,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Belinda J Gabbe, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I would like to thank the authors for their detailed answers and the revision of the manuscript after my comments.

Reviewer #2: Thank you for revising the paper. I enjoyed reading it and it is now suitable for publication in my opinion

Y

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Omar Bouamra

Reviewer #2: No