Are there differences between COVID-19 and non-COVID-19 inpatient pressure injuries? Experiences in Internal Medicine Units

Leticia Nieto-García; Adela Carpio-Pérez; María Teresa Moreiro-Barroso; Emilia Ruiz-Antúnez; Ainhoa Nieto-García; Montserrat Alonso-Sardón

doi:10.1371/journal.pone.0263900

Peer Review History

Original SubmissionJuly 28, 2021
24 Sep 2021 Decision Letter - Itamar Ashkenazi, Editor PONE-D-21-24374Are there differences between COVID-19 and non-COVID-19 inpatient pressure injuries? Experiences in Internal Medicine UnitsPLOS ONE Dear Dr. Alonso-Sardón, 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' comments are attached below. Both had differing recommendations whether to accept the paper or not. However, both are in agreement that there is significant bias due to patient selection. And both have suggestions on how to improve this manuscript. Since methodology is the major set back of this submission, it could be that the right choice should be to remove this submission, rewrite the paper focusing on the correct patient population. The reviewers seem to prefer the acute pressure injuries as the group to focus on. I still have my bias in also including the chronic wounds in a separate analysis, focusing on issues that were not even mentioned, such as how many of those with deep wounds were offered an operation to alleviate their problem. I leave it up to the authors to make a decision whether to retreive their paper and submit a revised paper focusing on a more limited homogenous group, or to try and revise their paper taking advantage of the suggestions made by both reviewers. Please submit your revised manuscript by Nov 08 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. 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We will update your Data Availability statement to reflect the information you provide in your cover letter. [Note: HTML markup is below. Please do not edit.] 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: Yes Reviewer #2: No ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know Reviewer #2: Yes ****** 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 ****** 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 ****** 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: Pressure injuries (PI) are a global health issue. The authors describe and compare epidemiological and clinical features of PIs in COVID-19 patients and patients admitted due to other causes in Internal Medicine Units during the first wave of COVID-19 pandemic. This study has a substantial inherent bias, performed during the COVID-19 pandemic, that may interfere with the main results. Though it was mentioned in the study limitations, it should be elaborated more specifically regarding the limits of the execution of PI prevention protocol in the COVID-19 group leading to their findings. The significant differences in PI staging are indicative of the acute onset of the wounds in the COVID-19 group. The mean hospital stay was significantly longer in the COVID-19 patient group. This may be explained by the effort to provide hospital beds for expected COVID-19 patients by discharging non-COVID patients from hospitals and admitting mainly severe cases. This research points out again the importance of PI prevention and delineates the restrictions and limitations imposed by the pandemic. Reviewer #2: This is a retrospective observational analysis of pressure injuries during the first wave of COVID-19 in Spain. However, it seems split between trying to describe individual level factors leading to pressure injury (COVID vs non-COVID) and systems level factors (overcrowding and administrative challenges during a COVID wave). For the COVID versus non-COVID analysis it isn't clear to me why patients with pre-existing pressure injuries (the majority of the cases) were included in the analysis. There are many sources of bias for this based on the age structure of COVID versus non-COVID patients and where they were admitted from (home vs subacute care). Also the pre-existing ulcers in COVID patients were likely unrelated to COVID since patients with severe disease usually present to the hospital within a few days to a week of exposure. If the authors want to focus in on the differences in pressure injuries arising from covid versus non-covid, I would only analyze incident cases during the surge, and also exclude non-covid cases that were admitted to the hospital prior to March 1, 2020 because that also adds in a lead-time bias. However the authors also seem interested in pressure injury incidence as an "indicator of the quality of care in acute settings" during the COVID surge which is also an interesting questions. However for that question, I think an analysis of a March-June 2019 vs March to June 2020 would be a more valid way to assess how systems level challenges affected pressure injuries. Additional notes: Introduction Line 69 - I would also add that isolation precautions have been associated with increased rates of pressure injuries Methods Line 108 - I'm still unclear on what an episode of care represents. If patients had multiple episodes were those separate admissions, or had the initial injury resolved but then a second one appeared? Line 118 - were patients who were first admitted prior to March 1 excluded? There could have been non-COVID patients who had extended inpatient stays prior to March would be a kind of lead-time bias since COVID wasn't present in Spain prior to then. Results Line 222 - How was an injury infection defined as opposed to wound colonization? Line 229 - All open ulcers are colonized with bacteria. Does "microbiological analysis" just mean that some were superficially swabbed for culture (which is irrelevant)? Or were these deep tissue surgical biopsies that are actually clinically relevant? Line 233 - Again, were these cultures superficial swabs or deep tissue biopsies? Superficial swabs do not often reflect the true etiology of wound infections (https://pubmed.ncbi.nlm.nih.gov/1523451/) and I'd take this portion out of the manuscript, unless they were deep cultures. Minor line 79 - It should be "chronic diseases" not "chronical diseases" ****** 6. 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:** Moris Topaz, M.D., Ph.D., Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0263900.r001
Revision 1
9 Nov 2021 Author Response 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. RESPONSE: Thank you to the editorial staff and reviewers for their recommendations that will increase the quality and interest of the manuscript; as well as, for the opportunity to send a revised version of the manuscript. Both reviewers' comments are attached below. Both had differing recommendations whether to accept the paper or not. However, both are in agreement that there is significant bias due to patient selection. And both have suggestions on how to improve this manuscript. Since methodology is the major set back of this submission, it could be that the right choice should be to remove this submission, rewrite the paper focusing on the correct patient population. The reviewers seem to prefer the acute pressure injuries as the group to focus on. RESPONSE: The authors revised and rewrote the paper following methodological suggestions made by both reviewers (homogenous group). I still have my bias in also including the chronic wounds in a separate analysis, focusing on issues that were not even mentioned, such as how many of those with deep wounds were offered an operation to alleviate their problem. RESPONSE: CRD were reviewed with the aim of collecting patients who required intervention by dermatology or plastic surgery. Taking into account the suggestion, the outcomes have been incorporated into the new manuscript. I leave it up to the authors to make a decision whether to retreive their paper and submit a revised paper focusing on a more limited homogenous group, or to try and revise their paper taking advantage of the suggestions made by both reviewers. RESPONSE: We, the authors, have reanalyzed the data following the suggestions of the reviewers and we submit a rewritten paper, including results and discussion sections, and the addition of new tables and figures Reviewers' comments: Reviewer #1: Pressure injuries (PI) are a global health issue. The authors describe and compare epidemiological and clinical features of PIs in COVID-19 patients and patients admitted due to other causes in Internal Medicine Units during the first wave of COVID-19 pandemic. This study has a substantial inherent bias, performed during the COVID-19 pandemic, that may interfere with the main results. Though it was mentioned in the study limitations, it should be elaborated more specifically regarding the limits of the execution of PI prevention protocol in the COVID-19 group leading to their findings. The significant differences in PI staging are indicative of the acute onset of the wounds in the COVID-19 group. The mean hospital stay was significantly longer in the COVID-19 patient group. This may be explained by the effort to provide hospital beds for expected COVID-19 patients by discharging non-COVID patients from hospitals and admitting mainly severe cases. This research points out again the importance of PI prevention and delineates the restrictions and limitations imposed by the pandemic. RESPONSE: Given your recommendation, a more extended paragraph has been elaborated in discussion related to the limits of the implementation of a PI prevention protocol in the COVID-19 group (Line 306). Reviewer #2: This is a retrospective observational analysis of pressure injuries during the first wave of COVID-19 in Spain. However, it seems split between trying to describe individual level factors leading to pressure injury (COVID vs non-COVID) and systems level factors (overcrowding and administrative challenges during a COVID wave). For the COVID versus non-COVID analysis it isn't clear to me why patients with pre-existing pressure injuries (the majority of the cases) were included in the analysis. There are many sources of bias for this based on the age structure of COVID versus non-COVID patients and where they were admitted from (home vs subacute care). Also the pre-existing ulcers in COVID patients were likely unrelated to COVID since patients with severe disease usually present to the hospital within a few days to a week of exposure. If the authors want to focus in on the differences in pressure injuries arising from covid versus non-covid, I would only analyze incident cases during the surge, and also exclude non-covid cases that were admitted to the hospital prior to March 1, 2020 because that also adds in a lead-time bias. RESPONSE: Done. The inclusion and exclusion criteria have been rewritten to make it clearer that the sample was collected from patients admitted from March 1 to June 1 in the Internal Medicine Service (excluding patients admitted before or after this period). However the authors also seem interested in pressure injury incidence as an "indicator of the quality of care in acute settings" during the COVID surge which is also an interesting questions. However for that question, I think an analysis of a March-June 2019 vs March to June 2020 would be a more valid way to assess how systems level challenges affected pressure injuries. RESPONSE: Data have been collected for the same period of the previous year and have been incorporated in the text for discussion (Line 190). Additional notes: Introduction Line 69 - I would also add that isolation precautions have been associated with increased rates of pressure injuries. RESPONSE: Done. Methods Line 108 - I'm still unclear on what an episode of care represents. If patients had multiple episodes were those separate admissions, or had the initial injury resolved but then a second one appeared? RESPONSE: Each episode of care represents the assessment, record and treatment of a PI. Line 118 - were patients who were first admitted prior to March 1 excluded? There could have been non-COVID patients who had extended inpatient stays prior to March would be a kind of lead-time bias since COVID wasn't present in Spain prior to then. RESPONSE: The inclusion criteria described in the manuscript have been revised to clarify this point. Only patients admitted from March 1 to June, 1, 2020 were included. Results Line 222 - How was an injury infection defined as opposed to wound colonization? RESPONSE: According to literature, colonization was defined as the presence of proliferating bacteria without a host response, and therefore does not restrain wound healing. However, infection is related to local and/or systemic host reaction with delayed wound healing. For this reason, the diagnosis of PI infection was combined, although eminently clinical and not only microbiological quantification. In all cases in the sample with infection diagnosis, the nursing staff reported indexes of clinical suspicion of local infection. Line 229 - All open ulcers are colonized with bacteria. Does "microbiological analysis" just mean that some were superficially swabbed for culture (which is irrelevant)? Or were these deep tissue surgical biopsies that are actually clinically relevant? Line 233 - Again, were these cultures superficial swabs or deep tissue biopsies? Superficial swabs do not often reflect the true etiology of wound infections (https://pubmed.ncbi.nlm.nih.gov/1523451/) and I'd take this portion out of the manuscript, unless they were deep cultures. RESPONSE: Although we understand that deep tissue biopsies is the gold standard for microbiological diagnosis of infection in pressure injuries, in clinical practice of our department, cultures are routinely taken by aspiration or superficial swabs. Its bias has been included in the limitations section for the reader´s consideration. Minor line 79 - It should be "chronic diseases" not "chronical diseases". RESPONSE: Corrected. Authors agree with the reviewers’ recommendations. We sent the manuscript as instructed. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0263900.r002
10 Dec 2021 Decision Letter - Itamar Ashkenazi, Editor PONE-D-21-24374R1Are there differences between COVID-19 and non-COVID-19 inpatient pressure injuries? Experiences in Internal Medicine UnitsPLOS ONE Dear Dr. Alonso-Sardón, Thank you for submitting your revised manuscript to PLOS ONE. After careful consideration, we still feel that there is a major deficit to be dealt with before it fully meet PLOS ONE’s publication criteria. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Jan 24 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Itamar Ashkenazi Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] 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 #2: (No Response) ******** 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 #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: No ****** 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 #2: Yes ****** 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 #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 #2: I appreciate your response to my earlier points and feel that the data presented is now much clearer. However, some of the conclusions don't seem to fit that new data. First, rates of HAPIs were low compared to a year earlier and compared to other literature, which is surprising especially as the age of patients was high with multiple comorbidities. You comment on this is "Although there is a lack of records of specific characteristics of PIs, authors considered that the assessment and management of wounds, as well as decision making of the treatment was probably carried out in situ during the assistance practice and the main reason of registered data loss were care overload and restructuring of nursing staff" which I don't really understand what you are trying to say. Are you saying that numbers of PIs were down because they weren't being accurately recorded? I think this is a major finding and requires more discussion of why you think it happened. You also place emphasis in the discussion on risk-factors for PI that had a P-value of <0.05 but your analysis has a large amount of comparisons so that value isn't appropriate and needs correction for multiple comparison (eg Bonferroni or Benjamini-Hochberg) or the conclusions should be much more circumspect and this limitation strongly emphasized. You conclude that "The study shows that HAPIs were more frequent in COVID-19 group during the first wave of COVID-19." but this is only comparing absolute numbers of HAPIs in COVID versus non-COVID. I think you need to compare rates (HAPIs per COVID patient-day versus HAPIs per non-COVID patient-day or HAPIs per COVID admission versus HAPIs versus non-COVID admission) to truly make this conclusion. ****** 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 #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0263900.r003
Revision 2
22 Jan 2022 Author Response Response to Reviewers Thank you to reviewer #2 for her recommendations that will increase the quality and interest of the manuscript; as well as, thank you to the editorial staff for the opportunity to send a revised version of the manuscript. Reviewers' comments: Reviewer #2: I appreciate your response to my earlier points and feel that the data presented is now much clearer. However, some of the conclusions don't seem to fit that new data. First, rates of HAPIs were low compared to a year earlier and compared to other literature, which is surprising especially as the age of patients was high with multiple comorbidities. You comment on this is "Although there is a lack of records of specific characteristics of PIs, authors considered that the assessment and management of wounds, as well as decision making of the treatment was probably carried out in situ during the assistance practice and the main reason of registered data loss were care overload and restructuring of nursing staff" which I don't really understand what you are trying to say. Are you saying that numbers of PIs were down because they weren't being accurately recorded? I think this is a major finding and requires more discussion of why you think it happened. RESPONSE: We have clarified this possible confusing point to improve the understanding of the discussion. As we pointed out in the discussion, the prevalence rate is lower than records of the previous year or other national studies, which may sound contradictory after taking into account the serious clinical status of the patients, the high mean age of the sample and pluripathologic condition. Regarding this point, we consider as a likely explanation that overloaded care and overall public health situation may have led to an under-registration of PIs because other registries and/or care were prioritized. Furthermore, in the discussion we tried to highlight that registered LPPs presented an incomplete record of specific characteristics of wounds such as depth, size, wound bed, etc. that were logged in some episodes. Only variables such as staging and location were completed in all episodes. You also place emphasis in the discussion on risk-factors for PI that had a P-value of <0.05 but your analysis has a large amount of comparisons so that value isn't appropriate and needs correction for multiple comparison (eg Bonferroni or Benjamini-Hochberg) or the conclusions should be much more circumspect and this limitation strongly emphasized. RESPONSE: Most of the variables analysed are categorical; only some variables, for example age or hospital stay, are continuous variables that allow comparisons by pairs of group means (Bonferroni Test), as we have done. The p-values shown in the tables correspond to the bivariate analysis, as indicated in the methodological section "statistical analysis". Multivariate analysis (logistic regression) was not included in the results because it did not show statistically and clinically significant results. You conclude that "The study shows that HAPIs were more frequent in COVID-19 group during the first wave of COVID-19." but this is only comparing absolute numbers of HAPIs in COVID versus non-COVID. I think you need to compare rates (HAPIs per COVID patient-day versus HAPIs per non-COVID patient-day or HAPIs per COVID admission versus HAPIs versus non-COVID admission) to truly make this conclusion. RESPONSE: GACELA-Care® was used for data collection. It uses the "episode of care" as the recording unit. Only total ulcer episode data were available, as figure 1 shows; these data have been exploited in the analysis for the estimation of prevalence and incidence (Results: section 1). Authors agree with the reviewers’ recommendations. We sent the manuscript as instructed. Attachments Attachment Submitted filename: Response_Reviewer.docx https://doi.org/10.1371/journal.pone.0263900.r004
31 Jan 2022 Decision Letter - Itamar Ashkenazi, Editor Are there differences between COVID-19 and non-COVID-19 inpatient pressure injuries? Experiences in Internal Medicine Units PONE-D-21-24374R2 Dear Dr. Alonso-Sardón, 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. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Itamar Ashkenazi Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0263900.r005
Formally Accepted
4 Feb 2022 Acceptance Letter - Itamar Ashkenazi, Editor PONE-D-21-24374R2 Are there differences between COVID-19 and non-COVID-19 inpatient pressure injuries? Experiences in Internal Medicine Units. Dear Dr. Alonso-Sardón: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Itamar Ashkenazi Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0263900.r006

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