PONE-D-23-09513Construction of a standardized training system for hospital infection prevention and control for new medical staff in internal medicine ICUs based on the Delphi methodPLOS ONE

Dear Dr. Tang,

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 submit your revised manuscript by Jul 13 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.

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Faizan Iqbal

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: Yes

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: No

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: Here are few suggestions/comments, incorporating specific examples from the article to support and substantiate each suggestion

Abstract:

• Instead of stating "positive results were obtained," provide the specific percentage or statistical measure to indicate the level of effectiveness or success achieved. For instance, you can mention that "the standardized training system resulted in a 40% reduction in healthcare-associated infections among medical staff in internal medicine ICUs."

• Include information about the significance and implications of the study findings. For example, highlight how the development of a standardized training system can contribute to improved patient safety, reduced healthcare costs, and enhanced overall quality of care in internal medicine ICUs.

Introduction/Background:

• Provide more context and background information on the current challenges or gaps in existing training systems for medical staff in internal medicine ICUs. For instance, discuss the prevalence of healthcare-associated infections and their impact on patient outcomes, emphasizing the need for effective infection prevention and control measures.

• Incorporate a brief review of relevant literature or previous studies that highlight the need for a standardized training system. For example, cite studies that have identified deficiencies in current training practices or have shown the positive impact of comprehensive training programs on infection control outcomes.

Methods:

• Provide a clear explanation of the selection criteria for the expert panel. Specify the desired qualifications or expertise sought in the experts who participated in the Delphi method. For example, state that experts were selected based on their experience in infection prevention and control, knowledge of internal medicine ICU practices, and familiarity with the Delphi method.

• Describe the measures taken to ensure the reliability and validity of the expert opinions collected through the Delphi method. For example, discuss how potential biases or conflicts of interest were addressed, such as ensuring anonymity and independence of the experts.

• Include a description of how consensus was determined in the Delphi process. Specify the criteria used to determine when expert opinions reached convergence or stability. For example, mention that consensus was considered achieved when at least 70% of experts agreed on a particular item or recommendation.

Results:

• Supplement the tables with brief explanatory text to help readers interpret and understand the key findings. For example, provide a concise summary of the main results, such as the percentage of experts agreeing on each item or the most commonly recommended training components.

• When discussing the expert authority coefficient and opinion coordination degree, explain these measures and their significance in assessing the level of agreement or consensus among the expert opinions. For example, state that the expert authority coefficient measures the level of expertise and influence of each expert, while the opinion coordination degree quantifies the degree of agreement among experts.

Discussion:

• Expand on the implications and potential applications of the study findings. For instance, discuss how the developed standardized training system can be implemented in real-world settings, highlighting its potential impact on reducing healthcare-associated infections and improving patient safety.

• Compare the developed system with existing training systems or guidelines in other similar healthcare settings. Discuss how the developed system differs or improves upon current practices. For example, highlight its adaptability to different ICU settings and its focus on evidence-based practices in infection prevention and control.

• Discuss limitations or potential challenges of the developed training system. Address factors such as feasibility, scalability, and sustainability, as well as potential barriers to implementation. Provide suggestions or strategies for addressing these limitations, such as incorporating ongoing evaluation and feedback mechanisms or considering tailored adaptations for different healthcare contexts.

Conclusion:

• Provide a concise and impactful summary of the study findings and their implications. Emphasize the significance of the developed standardized training system in improving infection prevention and control in internal medicine ICUs, emphasizing its potential to enhance patient safety and reduce healthcare-associated infections.

• Highlight the broader relevance and applicability of the research beyond the specific study setting. Discuss the potential for adaptation or adoption of the developed system in other healthcare institutions or settings, both nationally and internationally. For example, mention that the standardized training system could be implemented in various internal medicine ICUs across different countries, leading to standardized practices and improved infection prevention and control outcomes.

References:

• Ensure that all references cited in the text are included in the reference list, and vice versa. Cross-reference the in-text citations with the corresponding entries in the reference list to ensure accuracy and completeness. For example, in the introduction section, the study references previous research on the importance of infection prevention and control in healthcare settings. It is important to verify that these references are correctly listed in the reference list and that there are no missing citations.

General Feedback:

• Pay attention to the overall flow and organization of the article. Ensure that the sections logically progress from one to another and that the content within each section is well-structured. For instance, in the methods section, there could be a more systematic and clear presentation of the steps involved in the Delphi method. This would enhance the overall organization and readability of the section.

• Review the article for grammatical and syntactical errors to improve clarity and readability. For example, in the results section, there are instances of inconsistent tense usage, such as switching between past and present tense within the same paragraph. These inconsistencies should be corrected to maintain consistency throughout the manuscript.

• Check for compliance with the STROBE guidelines for observational studies. Ensure that the study design, data collection, and analysis methods align with the recommended reporting standards. For example, in the methods section, it would be beneficial to provide more details on the participant recruitment process and any eligibility criteria used. This information is essential for readers to understand the study population and potential biases.

By addressing these feedback and suggestions, the article can be strengthened in terms of scientific rigor, clarity, and overall quality.

Reviewer #2: The article used appropriate methods in proposing a standardised training system of infection prevention and control for new medical staff in the internal medicine ICU in two provinces in China. It is an important addition to literature on improving the prevention of nosocomial infections through appropriate and affection training. However, some clarification and suggested revisions are required to improve the quality of the manuscript. Below are some of the comments:

1. In the abstract, a statement/sentence on the subject matter in China will be appropriate in providing the study context.

2. "The Kendall coordination coefficients of the first-, second-, and third-level indicators were 0.440, 0.204, and 0.386 (P <0.001), 0.562, 0.467 and 0.556(P <0.001)." Authors should clarify which of the reported coefficients are from the first round of survey and which are from the second.

3. The study setting is in China, however no background information on nosocomial infection in the country was provided in the introduction. It is essential to provide such information in the introductions for context.

4. "Upon comparing the features of the ICU and other wards, we found that patients in the ICU had more invasive treatments and were more prone to infections than patients from other wards." Provide more details on how this comparison was done.

5. "After reading the retrieved literature abstracts, we screened for eligible studies and extracted frequently appearing items of interest for this present study." Define what the "items of interest" are in the study design.

6. As highlighted in the introduction, doctors and nurses from different regions and countries have different ideas regarding the content, type and mode of hospital infection prevention and control training. The results would have been greatly improved and more generalizable if participants were selected from different provinces and cities across the country.

7. The text under participants needs some clarification. The authors indicated that 16 expert were purposively sampled for two rounds of questionnaires. They later indicate that the "subject" finally selected 16 experts. Who is/are the "subjects" here and are these 16 experts different from the ones who answered the questionnaires? If yes, how were they engaged in the study?

8. In the selection criteria for the experts, the authors indicated “bachelor's degree or above” and “intermediate certificate or above”. If they are both academic certificates, having both in your selection criteria means the participant must have both in order to be selected to participate in the study.

9. How many hospitals from each province where participants selected from?

10. "We conducted semi-structured interviews with 2 nursing team leaders and 3 new nurses in the internal medicine ICU in March 2022." Why were the semi-structured interviews conducted with only 5 nurses? Where they all from the same hospital? Were the doctors and technicians not engaged for interviews?

11. The “delphi consulting and feedback cycle” and the “expert letter questionnaire” could be merged into one section.

12. The authors need to provide details on how the familiarity and judgement coefficients were calculated.

13. "In the first round, according to the exclusion criteria and expert opinions, combined with the discussion of the research group, the research team added the feasibility evaluation of the items and gave the training time for the training content of hospital infection, following which 2 indicators were merged, 6 indicators were deleted, 6 indicators were added, and 1 indicator was modified." What are these “exclusion criteria” and how where they determined?

14. "In the second round, the research group changed 2 indicators, eliminated 1 indicator, and merged 1 indicator. " Do the author mean 2 indicators were merged?

15. "Of the 16 experts, 7 specialized in nosocomial infection management, 3 were well-known experts in the field of hospital infection management nationwide, 9 specialized in intensive care, 6 were ICU head nurses, and 3 specialized in hospital infection management.” Do some of the experts have multiple specializations? Are the 3 well-known experts in the field of hospital infection management nationwide the same as the 3 specialized in hospital infection management?

16. The structure of the discussion could be improved to make the content flow better for easy comprehension. For instance, the initial part of the third paragraph of the discussion section “In China, there is a shortage of medical resources, and medical staff usually have intensive working hours and cannot complete all training before entering clinical practice. Thus, the short-cycle centralized training method of the proposed model is more in line with the Chinese ICU hospital settings, which helps to quickly combine knowledge and practice and improve the ability and quality of ICU medical staff to manage hospital infection” could be move to the last section of the same paragraph to improve the flow

17. "Among the three-level indicators, "hand hygiene, prevention and control of multidrug-resistant bacteria, and correct wearing and taking off of protective equipment" had the highest weight." Each of the indicators in this sentence should be in quotation marks to be identified as different indicators "Among the three-level indicators..." should be written as "Among the level three indicators..."

18. There a few punctuation and sentence structures errors. For instance, the last sentence under data collection needs to be qualified. Also avoid sub-headings in the discussion

19. "Based on the KAPB model, this study constructed a standardized training system for hospital infection prevention and control for new medical staff in the internal medicine ICU through literature research, qualitative interviews, expert interviews and AHP." The AHP has not been defined and not presented in the methods

20. The authors should also discuss the limitations of the study

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Reviewer #1: Yes: Adepoju Victor Abiola

Reviewer #2: No

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PONE-D-23-09513R1Construction of a standardized training system for hospital infection prevention and control for new medical staff in internal medicine ICUs based on the Delphi methodPLOS ONE

Dear Dr. Tang,

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 submit your revised manuscript by Nov 30 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 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,

Arghya Das, MD

Academic 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.

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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: Not applicable. The authors have met all the above listed criteria. There was no dual publication, research ethics, or publication ethics

Reviewer #2: The authors have significantly improved the content and structure of the manuscript and have addressed the comments appropriately.

Below are a few corrections required:

1. The authors can join the sentences in line 45 with a conjunction

2. Avoiding subheadings in the discussion is ideal

3. Line 327 seems to be incomplete.

4. The section on limitation could be inserted as the last paragraph in the discussion section

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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: Victor Abiola Adepoju

Reviewer #2: No

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[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.

Construction of a standardized training system for hospital infection prevention and control for new medical staff in internal medicine ICUs based on the Delphi method

PONE-D-23-09513R2

Dear Dr. Tang,

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,

Arghya Das, MD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: