PONE-D-21-25450

Triaging and Referring In Adjacent General and Emergency Departments (the TRIAGE trial): a cluster randomised controlled trial

PLOS ONE

Dear Dr. Morreel,

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.

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Andrej M Kielbassa

Academic Editor

PLOS ONE

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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: No

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: 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

Reviewer #3: No

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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

Reviewer #3: 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: Abstract

- Maximum word count is 300. Please see Guidelines for Authors, and shorten accordingly.

- "(...) nurse-led triage using a new tool assigning patients (...)" - meaning remains unclear, please add information.

- "(...) in the control group 431/1744 (24.7%, 95% CI 22.7 to 26.8)." Please provide complete sentences.

- What is meant when referring to "MTS presentational flowchart"? Please clarify.

- "ED nurses using a new tool safely diverted 9.5% of the included patients to primary care." This does not refer to your aims/objectives. Please revise carefully.

Intro

- Again, please note that your draft does not follow the Authors' Guidelines. Revise referencing, "(...) in a primary care setting.[1-4]" must read "(...) in a primary care setting [1-4]." Revise thoroughly.

- "Three small non randomised trials about the MTS and diversion to primary care revealed promising results [14-16]." Rationale would seem unclear. Please elaborate both aims and objectives more clearly.

- What about your null hypothesis? Remember that H0 must be deducible from the foregoing thoughts.

Meths

- Again, please note that your draft does not follow the Authors' Guidelines. Revise for "Material and methods".

- Would seem complete.

Results

- Convincingly elaborated.

Disc

- Please stick to H0 when starting this section.

- "The referral rate of patients in the primary outcome to the ED (4%) was similar to the referral rate of the studied GPC for untriaged patients (6%) and in general practice OOH services in the United Kingdom (8.1%)." Reference missing.

Concl

- With your Conclusions, please stick exclusively to your revised aims. Do not simply repeat your results here. Instead, provide a reasonable and generalizable extension of your outcome.

Refs

- Please revise for uniform formatting. Compare "The American journal of emergency medicine. 2011;29(3):333-45.", "BMJ. 2020;368:m462. doi:10.1136/bmj.m462.", or "Journal of emergency management (Weston, Mass). 2016;14(5):349-64. doi: 10.5055/jem.2016.0300. PubMed PMID: 27873299.", and re-edit thoroughly.

In total, this is an interesting paper, easily intelligible, and should be worth following after revision.

- doi and PMID numbers will be sufficient.

Reviewer #2: Thank you for giving me the opportunity to review the article entitled: "Triaging and Referring In Adjacent General and Emergency Departments (the TRIAGE trial): a cluster randomised controlled trial". This is a very interesting study on a topic that is becoming more and more relevant and that is increasingly affecting EDs in countries with an open and public health care system.

The use of the GPC strategy can be interesting and the results of the study demonstrate this.

On the other hand, there are some points that might need clarification.

In the methods section it would be interesting to indicate which diagrams were not changed in this new eMTS version.

In the results section it is indicated that the majority of patients assigned to GPC were a blue code, it would be interesting to compare the proportions (total blue patients and percentage of patients who used GPC vs total green patients and percentage of patients who used GPC). This is because in the most well-known MTS studies it is known that the majority of patients are green and a small proportion blue, this could give an accurate idea of the impact of this strategy.

Also, in the results section it is indicated that most of the patients eligible for GPC were detected on weekends, why? Are there more weekend accesses, are there no other types of services presents? Are the proportions of codes equal between weekend and week (or are there more green and blue due to the absence of some services)?

On page 17 it is stated that one patient elected for the GPC strategy died. Regardless of the individual case, this may also be the case in other non-specific symptom presentations that result in a more serious underlying condition (epigastric pain in a diabetic patient that results in a acute myocardial infarction, mild abdominal pain that results in appendicitis). There are different reports on individual symptom presentations and the functionality of MTS, and some of these indicate that patients with green and blue codes have a subsequent severe and time-dependent pathology (DOI: 10.1016/j.ienj.2020.100842; DOI: 10.1177/1474515118777402; DOI: 10.1111/jocn.15635). This might be an interesting aspect to be addressed in the discussion.

In supplementary table S9-T2 it is reported that a patient with adult unwell chart presented with the diagnosis of headache and so on, was the correct application of MTS assessed? If not, it could result as a limitation of the study.

Another aspect that could be included as a limitation of the study is the fact that the GPC physician may have altered their performance in patients sent from triage. Could he have decreased the rates of patients sent back to the ED given this knowledge? This limitation is given by the type of study but still deserves to be mentioned in the limitations section.

Despite these minor concerns the article is very interesting and explores a useful strategy for the performance of the ED, the impact of this strategy could be revolutionary for EDs and triage. The article is well written and clear.

Reviewer #3: A cluster randomized control study was conducted which aimed to determine the effectiveness and safety of a tool diverting patients eligible for primary care from an ED to the adjacent general practitioner cooperative (GPC). The primary outcome was the proportion of patients assigned to and handled by the GPC during intervention weekends. Randomization took place only for the secondary outcome: determining the proportion of patients assigned to GPC during intervention and control weekends.

Minor revisions:

1- Table 1: State the statistical testing methods used to estimate the p-values.

2- Table 2: To improve clarity, modify the title to include “logistic regression bivariate analysis.”

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Reviewer #1: No

Reviewer #2: Yes: Zaboli Arian, RN, Emergency Department, Hospital of Merano

Reviewer #3: No

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Triaging and Referring In Adjacent General and Emergency Departments (the TRIAGE trial): a cluster randomised controlled trial

PONE-D-21-25450R1

Dear Dr. Morreel,

After having double checked your revised and re-submitted paper, I am 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, congratulations and compliments, and stay healthy

Andrej M Kielbassa, Prof. Dr. med. dent. Dr. h. c.

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

Reviewer #3: 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

Reviewer #3: (No Response)

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: (No Response)

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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

Reviewer #3: (No Response)

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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

Reviewer #3: (No Response)

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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: This revised and re-submitted draft would seem satisfying. Depending on the external reviewers' recommendations, it is considered ready to proceed.

Reviewer #2: Thank you for clarifying the points I highlighted in the previous review. I thank the authors for responding and editing their article according to the suggestions of the reviewers and the Editor.

I think this is a very interesting topic, it is well known that EDs around the world suffer from excessive influx for their organizations and these solutions and strategies are needed and it is extremely important to study them. That is why I think the article in its current form is appropriate for the journal.

Reviewer #3: (No Response)

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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: No

Reviewer #2: No

Reviewer #3: No