Three-year hospital-wide pain management system implementation at a tertiary medical center: Pain prevalence analysis

Ming-Chuan Chen; Te-Feng Yeh; Chih-Cheng Wu; Yan-Ru Wang; Chieh-Liang Wu; Ruei-ling Chen; Ching-Hui Shen

doi:10.1371/journal.pone.0283520

Peer Review History

Original SubmissionSeptember 15, 2022
6 Dec 2022 Decision Letter - Christina Abdel Shaheed, Editor PONE-D-22-25681Three-year hospital-wide pain management system implementation at a tertiary medical center: pain prevalence analysisPLOS ONE Dear Dr. Shen, 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. Please address each point raised by the reviewer and myself and provide your responses to each. Some feedback can be found in the annotated pdf file. Please submit your revised manuscript by Jan 20 2023 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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The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information. Additional Editor Comments: This is an interesting study however I have specific comments for the authors to consider. Please see annotations in the pdf file. [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 ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: 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 ****** 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 ****** 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: Dear Team, thankyou for the opportunity to review the submission. The manuscript looked at evaluating the effect of a hospital wide pain management campaign and collected outcomes between 2018-2020. The details and information within the manuscript were presented in a sequence manner to describe the project design and the findings. There are a few minor comments to provide to see if these could be potential suggestions that could be reviewed: Abstract: Not to certain if this may be a typo, but a minor revision is required: The prevalence 28 rates of pain experienced by the patients in the 3-year period were 69.5% (2018) (reference) Methods: -Exclusion criteria: could you provide some examples of critical illness (e.g. cancer, heart/renal failure, patients receiving chemotherapy) to help better understand those that were not suitable for the study. Was pregnancy also excluded for the trial? -Monitoring of those administering/reviewing the pain management program: This does not require an amendment to the manuscript and/or study design, but be keen to hear comments if there would be scope to undertake check-ups on process (e.g. 3 monthly) together with the 1 year that was initially undertaken for the study. Results: Demographics- Disease categories. Were any of the participants enrolled into the study present with multiple disease categories? it may be worthwhile to see if this could impact on the response rates for the survey Ethnicity- Not listed in the demographics but be good to see the population being assessed Results: Was the prevalence rates (pain) 2020 (60.1%) with inclusion of numbers during covid? Did the researchers feel the management was affected during the covid period as the rates of moderate severe pain increased in 2020? This would be understandable given the covid pandemic and the challenges the health practitioners may have experienced to manage an influx of patients during this period. ****** 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: 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. Attachments Attachment Submitted filename: PONE-D-22-25681_CAS.pdf https://doi.org/10.1371/journal.pone.0283520.r001
Revision 1
18 Jan 2023 Author Response In email, Review#1 Comments to the Author Abstract: Not to certain if this may be a typo, but a minor revision is required: The prevalence 28 rates of pain experienced by the patients in the 3-year period were 69.5% (2018) (reference) We changed it to “During the three-year period, the prevalence of pain was 69.5% (2018) (reference), 63.3% (2019) (OR:0.768, p<0.01), and 60.1% (2020) (OR:0.662, p <0.001).” Thank you for your advice. Methods: -Exclusion criteria: could you provide some examples of critical illness (e.g. cancer, heart/renal failure, patients receiving chemotherapy) to help better understand those that were not suitable for the study. Was pregnancy also excluded for the trial? This is a misapplication of the wording and should be replaced by unstable medical condition, that refers to a state in which the condition is so unstable that pain cannot be clearly expressed, such as shock, coma, etc. Therefore, patients with pregnancy, cancer, and cardiovascular disease were not excluded unless they were unable to express themselves. Thanks for your helpful comments. -Monitoring of those administering/reviewing the pain management program: This does not require an amendment to the manuscript and/or study design, but be keen to hear comments if there would be scope to undertake check-ups on process (e.g. 3 monthly) together with the 1 year that was initially undertaken for the study. Some of our Pain-Free Hospital Management Committee comments on the program are as follows. (1) Medical staff usually say to male patients that "pain is normal and must be tolerated". Medical staff need to minimize stereotypes. We should face up to everyone’s pain problem. (2) Patients with advanced age and low education level are more difficult to use the numerical rating scale. It is recommended that medical staff choose appropriate assessment tools for different patients. (3) Patients with severe pain and pain from injection and blood drawing are high-risk groups of side effects after taking analgesics. Medical staff should pay attention to the occurrence of side effects after taking analgesics. (4) The interface of the information system should be tested and optimized as early as possible, so that the subsequent guidance and application will be smoother. Results: Demographics- Disease categories. Were any of the participants enrolled into the study present with multiple disease categories? it may be worthwhile to see if this could impact on the response rates for the survey Ethnicity- Not listed in the demographics but be good to see the population being assessed This is a typo, and we changed it to “Medical department”, which refers to the department that provides primary care while hospitalized. This study did not investigate the patient's disease and race, and we hope to work on this part in the future. Results: Was the prevalence rates (pain) 2020 (60.1%) with inclusion of numbers during covid? Did the researchers feel the management was affected during the covid period as the rates of moderate severe pain increased in 2020? This would be understandable given the covid pandemic and the challenges the health practitioners may have experienced to manage an influx of patients during this period. Because of COVID-19 outbreak, part of the ward was converted into a negative pressure isolation room. That part of the ward was excluded from sampling at the time, so 1,025 samples were collected in 2020 (N=1034 in 2018 and N=1035 in 2019). At that time, the workload of medical staff increased, so the work of pain management may be relatively neglected. We think this may be related to the elevated prevalence of moderate to severe pain in 2020. Thank you for giving us the opportunity to strengthen our manuscript with your valuable comments and queries. We attach importance to your feedback and hope that these revisions persuade you to accept our submission. Sincerely, Dr. Ming-Chuan Chen chen510156@gmail.com Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0283520.r002
24 Jan 2023 Decision Letter - Christina Abdel Shaheed, Editor PONE-D-22-25681R1Three-year hospital-wide pain management system implementation at a tertiary medical center: pain prevalence analysisPLOS ONE Dear Dr. Shen, 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. It is important to describe the patient population more clearly. You refer to cancer guidelines, but were all the patients cancer patients? The management of cancer and non-cancer pain are quite different. Was the model you used applies to both groups of patients and if so, what is the justification for this? Please submit your revised manuscript by Mar 10 2023 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, Christina Abdel Shaheed Guest Editor PLOS ONE Journal Requirements: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] [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.0283520.r003
Revision 2
4 Mar 2023 Author Response Dear reviewer: Thank you for inviting us to submit a revised draft of our manuscript entitled, “Three-year hospital-wide pain management system implementation at a tertiary medical center: pain prevalence analysis” to PLoS One. We also appreciate the time and effort you have dedicated to providing insightful feedback on ways to strengthen our paper. Thus, it is with great pleasure that we resubmit our article for further consideration. We have incorporated changes that reflect the detailed suggestions you have graciously provided. We also hope that our edits and the responses we provide below satisfactorily address all the issues and concerns you have noted. To facilitate your review of our revisions, the following is a point-by-point response to the questions and comments delivered in your letter. 1. It is important to describe the patient population more clearly. The detailed description of patient population in the article is as follows. This study is a three-year longitudinal survey. All inpatients in general wards of Taichung Veterans General Hospital were the research subjects. The patients were enrolled if they (1) were at least twenty years old, (2) had a hospital stay of at least three days, (3) had clear consciousness, and (4) provided consent to be included in this study. Patients were excluded if they were not able to express themselves e.g., had dementia, brain injury, or unstable medical condition, such as shock or unconsciousness. In total, 1034, 1035, and 1025 patients were recruited by quota sampling from wards in 2018, 2019, and 2020, respectively. A total of 3094 inpatients completed the survey in this study, including 1679 males (54.3%) and 1415 females (45.7%). They were divided into six groups according to age, among which 789 patients (25.5%) were aged 60-69. They were divided into five groups according to body weight, among which 966 patients (31.2%) accounted for 60-69 kg. 898 patients (29.0%) had a college education or above, followed by senior high school (27.4%), elementary school (21.8%), junior high school (14.9%), and illiterate (6.9%). In terms of marital status, most of the 2380 (76.9%) were married, and the number of married people increased year by year, while the ratio of others (divorced, separated, widowed) decreased year by year. Patients from the Department of Internal Medicine (47.3%) and Department of Surgery (41.5%) were the main patients. Patients with (51.1%) and without (48.9%) undergoing surgery accounted for about half. 2. You refer to cancer guidelines, but were all the patients cancer patients? The management of cancer and non-cancer pain are quite different. Was the model you used applies to both groups of patients and if so, what is the justification for this? In response to the Towards a Pain-Free Hospital policy, considering the resources of the hospital and the feasibility of the policy, we hoped to develop a set of methods to cooperate with the dashboard system to monitor and identify patients with difficulty in pain management. Thus, we referred to the 3-3-3 principle and designed an approach termed “3324” for all pain monitoring in the hospital. This number means that the scale of VAS was > 3 and occurred ≥ 3 times within the last 24 hours during hospitalization. The data of patients who meet the criteria of 3324 will be displayed in the Dashboard Pain Management System, and the nurses and physicians can see it on the working panel of the electronic medical record system. The medical staff then take the necessary actions to control the patients’ pain following the process. If the patient still has refractory pain, the case manager of pain (a nurse) can visit the patient and consult with a pain specialist (anesthesiology) to adjust the analgesic prescription or consider regional analgesic therapies, such as peripheral nerve block. We hope to use this to identify inpatients who have difficulty in pain management immediately, and consult pain physicians to provide individualized treatment based on the patient’s condition, so as to improve the quality of pain management in the hospital. Thank you for giving us the opportunity to strengthen our manuscript with your valuable comments and queries. We attach importance to your feedback and hope that these revisions persuade you to accept our submission. Sincerely, Dr. Ming-Chuan Chen chen510156@gmail.com Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0283520.r004
12 Mar 2023 Decision Letter - Christina Abdel Shaheed, Editor Three-year hospital-wide pain management system implementation at a tertiary medical center: pain prevalence analysis PONE-D-22-25681R2 Dear Dr. Shen, 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, Christina Abdel Shaheed Guest Editor PLOS ONE Additional Editor Comments (optional): Thank you for your responses to my query. I think the responses are satisfactory. Reviewers' comments: https://doi.org/10.1371/journal.pone.0283520.r005
Formally Accepted
3 Apr 2023 Acceptance Letter - Christina Abdel Shaheed, Editor PONE-D-22-25681R2 Three-year hospital-wide pain management system implementation at a tertiary medical center: pain prevalence analysis Dear Dr. Shen: 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 Christina Abdel Shaheed Guest Editor PLOS ONE https://doi.org/10.1371/journal.pone.0283520.r006

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