Regional anaesthesia practice in public hospitals in Botswana: A cross-sectional study

Mamo Kassa; Farai Madzimbamuto; Gaone Kediegite; Eugene Tuyishime

doi:10.1371/journal.pone.0295932

Peer Review History

Original SubmissionApril 6, 2023
29 Jun 2023 Decision Letter - Silvia Fiorelli, Editor PONE-D-23-09813Regional anaesthesia practice in public hospitals in Botswana: A cross-sectional studyPLOS ONE Dear Dr. Tuyishime, 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. ACADEMIC EDITOR: Please revise the manuscript according to the reviewers' suggestions. Please submit your revised manuscript by Aug 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. 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, Silvia Fiorelli Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. 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 (1) whether consent was informed and (2) 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. If you are reporting a retrospective study of medical records or archived samples, please ensure that you have discussed whether all data were fully anonymized before you accessed them and/or whether the IRB or ethics committee waived the requirement for informed consent. If patients provided informed written consent to have data from their medical records used in research, please include this information. 3. We note that Figure 1 in your submission contain map images which may be copyrighted. All PLOS content is published under the Creative Commons Attribution License (CC BY 4.0), which means that the manuscript, images, and Supporting Information files will be freely available online, and any third party is permitted to access, download, copy, distribute, and use these materials in any way, even commercially, with proper attribution. For these reasons, we cannot publish previously copyrighted maps or satellite images created using proprietary data, such as Google software (Google Maps, Street View, and Earth). For more information, see our copyright guidelines: http://journals.plos.org/plosone/s/licenses-and-copyright. We require you to either (1) present written permission from the copyright holder to publish these figures specifically under the CC BY 4.0 license, or (2) remove the figures from your submission: a. You may seek permission from the original copyright holder of Figure 1 to publish the content specifically under the CC BY 4.0 license. We recommend that you contact the original copyright holder with the Content Permission Form (http://journals.plos.org/plosone/s/file?id=7c09/content-permission-form.pdf) and the following text: “I request permission for the open-access journal PLOS ONE to publish XXX under the Creative Commons Attribution License (CCAL) CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/). Please be aware that this license allows unrestricted use and distribution, even commercially, by third parties. Please reply and provide explicit written permission to publish XXX under a CC BY license and complete the attached form.” Please upload the completed Content Permission Form or other proof of granted permissions as an "Other" file with your submission. In the figure caption of the copyrighted figure, please include the following text: “Reprinted from [ref] under a CC BY license, with permission from [name of publisher], original copyright [original copyright year].” b. If you are unable to obtain permission from the original copyright holder to publish these figures under the CC BY 4.0 license or if the copyright holder’s requirements are incompatible with the CC BY 4.0 license, please either i) remove the figure or ii) supply a replacement figure that complies with the CC BY 4.0 license. Please check copyright information on all replacement figures and update the figure caption with source information. If applicable, please specify in the figure caption text when a figure is similar but not identical to the original image and is therefore for illustrative purposes only. The following resources for replacing copyrighted map figures may be helpful: USGS National Map Viewer (public domain): http://viewer.nationalmap.gov/viewer/ The Gateway to Astronaut Photography of Earth (public domain): http://eol.jsc.nasa.gov/sseop/clickmap/ Maps at the CIA (public domain): https://www.cia.gov/library/publications/the-world-factbook/index.html and https://www.cia.gov/library/publications/cia-maps-publications/index.html NASA Earth Observatory (public domain): http://earthobservatory.nasa.gov/ Landsat: http://landsat.visibleearth.nasa.gov/ USGS EROS (Earth Resources Observatory and Science (EROS) Center) (public domain): http://eros.usgs.gov/# Natural Earth (public domain): http://www.naturalearthdata.com/ 4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. [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: Partly Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: No Reviewer #2: No ****** 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: No 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: Thank you for inviting me to review this manuscript, which presents the results of a study to describe the regional anesthesia capacity, characteristics of regional anesthesia practice, and challenges and solutions to practicing safe regional anesthesia in public hospitals in Botswana. The study is on an interesting topic, of broad interest to the readership and I applaud the authors for undertaking this study, and their attempts to raise awareness about regional anesthesia practices. General comments: The work is overall clearly presented and easy to read. In my opinion, the major weakness of the study relates to the methods; participant selection, data collection, and analysis Specific comments: Keywords- it is better to add Botswana, than repetitions Competing interest – delete he/the--- ES. Line 1 - resources settings Purposive sampling-not clearly stated and implemented in the methods section. approximately 76 nurse anesthetists and 18 anesthesiologists in public hospitals- the figure is since 2021 but there has been an ongoing residency program All anesthesia providers were contacted and requested to complete the paper form of the study questionnaire sent to the chief of the anesthesia department by courier. Why do you need to use a courier when there are electronic data collection options? A purposive sampling method of public hospitals was used to achieve representation of different hospital levels across the Botswana health system- however, most of the participant was from Prince Marina Hospital (PMH)- 23 (60.5). Result section Table 1. N=38 It is good to mention the numerical value and then the percentage in a bracket Age total=37 where is the remaining 1 Prince Marina Hospital (PMH)- 23 (60.5) of the study participant were from a single hospital and how the figures in this study will be inferred from the practice of regional anesthesia in Botswana What is the essence of investigating the sociodemographic status of anesthesia providers unless it has a statistical analysis in association with the practice Table 2. Regional anesthesia capacity (anesthesia providers, procedures, equipment, supplies, and drugs) for public hospitals in Botswana How do we know the specific practice is not performed either due to a lack of knowledge and skills or basic essential equipment for each regional anesthesia technique? Table 3: N= 38 Regarding the technique of block, what do “N-37” and “%” implies? A single anesthesia provider can use three of the approaches mentioned and the figure depicted in the table needs elaboration. The same is true for the rest of the sub-topics in the table. RA-training- Only 24 (63.1) have formal training at the University or a short course in regional anesthesia but all the study participants can at least perform spinal anesthesia. Is that possible to practice without any training, how is the standard of practice negotiated here? Table 4: It would have been good thematically analyze the challenges in terms of academic qualification, institution, and year of experience … with its mitigation strategies Discussion and conclusions: Those are elaborations of the whole study with other similar studies and the findings. Hence, the discussion shall be revised based on the feedback raised in the methods and result section. It needs to be revised and needs to be very clear about what this adds to the existing literature and clearly details learning points. Overall needs a further major revision of the methodology, English grammar, and syntax to write in a scientific voice fashion and the journal protocols. Reviewer #2: Dear authors, here you receive my remarks concerning the manuscript entitled “Regional anaesthesia practice in public hospitals in Botswana: A cross-sectional study” and Short Title: Regional anaesthesia practice in public hospitals in Botswana with number PONE-D-23-09813. The authors present a observational study and show the results of cross-sectional survey among anesthesia providers working in public hospitals in Botswana. The article is well written and provides a clear cut idea and simple statistics. A number approval of the medical ethical board is provided. I think that it is an interesting manuscript and important for the situation in Botswana concerning the daily practice in regional anesthesia. I have a few remarks: Abstract: (Results)… by a small number of participants one referral hospital. Please change into:…by a small number of participants in one referral hospital. P5 Setting of the study. Is it possible to provide some more information about the greater perspective, i.e. how many anesthesia providers are there in total? You mention about 76 nurse anesthetists and 18 anesthesiologists. Am I correct that you received only from 4 anesthesiologists an answer concerning the survey? How many hospitals are there actually? You mention 25 (Figure 2)! It would improve understanding to actually relate your results in the greater perspective of the total and in what way it is the best representing sample provided here? P13 Can you tell us in how many of the cases locoregional anesthesia was used in relation of the number that could have been performed and was chosen to perform general anesthesia due to the reasons mentioned in Table 4, with of course the exclusion of the patients who did not choose locoregional anesthesia? In other words, is it possible for instance to calculate how many women in labour received general anesthesia and could have received spinal anesthesia but due to the reasons presented in Table 4 this did not happen. This is only easy one example, there may be more. Regarding Table 4: Did you become aware of shortage also to treat possible Local anesthetic systemic toxicity (LAST). Any idea about the incidence and the outcome of this serious complication? Textual: Do you mean “limited resources settings" or limited resource settings? Please compare when searching in the internet? Reference double! Ref 13= ref23 ****** 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 Reviewer #2: Yes: P. Bruins ******** [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.0295932.r001
Revision 1
5 Jul 2023 Author Response Eugene TUYISHIME, MBBS, MSc, 05th July, 2023 Anesthesiologist Assistant Program Director, Anesthesia and Critical Care department University of Botswana, Phone: + 26774504984 Email: tuyishime36@gmail.com To: Editor of Plos One Journal Dear Editor, RE: Re-submission of the manuscript/PONE-D-23-09813 entitled “Regional anaesthesia practice in public hospitals in Botswana: A cross-sectional study” I am pleased to submit a revised version of our study to Plos One journal. Our responses to your comments and the reviewer’s questions are highlighted in text in blue both in this letter and the manuscript text. Thank you for your consideration. Sincerely, Dr Eugene Tuyishime Editor and Reviewer Comments:   Academic Editor (Silvia Fiorelli) Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdfand https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf We have addressed the style requirements as suggested. 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 (1) whether consent was informed and (2) 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. If you are reporting a retrospective study of medical records or archived samples, please ensure that you have discussed whether all data were fully anonymized before you accessed them and/or whether the IRB or ethics committee waived the requirement for informed consent. If patients provided informed written consent to have data from their medical records used in research, please include this information. We have provided details about informed consent in the data collection process section as follows: . “Each participant provided a written consent prior to completing the questionnaire.” 2. We note that Figure 1 in your submission contain map images which may be copyrighted. All PLOS content is published under the Creative Commons Attribution License (CC BY 4.0), which means that the manuscript, images, and Supporting Information files will be freely available online, and any third party is permitted to access, download, copy, distribute, and use these materials in any way, even commercially, with proper attribution. For these reasons, we cannot publish previously copyrighted maps or satellite images created using proprietary data, such as Google software (Google Maps, Street View, and Earth). For more information, see our copyright guidelines: http://journals.plos.org/plosone/s/licenses-and-copyright. We require you to either (1) present written permission from the copyright holder to publish these figures specifically under the CC BY 4.0 license, or (2) remove the figures from your submission: We have removed Figure 1 from our re-submission. 4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. We have not submitted any extra files. Reviewer #1: Thank you for inviting me to review this manuscript, which presents the results of a study to describe the regional anesthesia capacity, characteristics of regional anesthesia practice, and challenges and solutions to practicing safe regional anesthesia in public hospitals in Botswana. The study is on an interesting topic, of broad interest to the readership and I applaud the authors for undertaking this study, and their attempts to raise awareness about regional anesthesia practices. Thank you for your feedback. General comments: The work is overall clearly presented and easy to read. In my opinion, the major weakness of the study relates to the methods; participant selection, data collection, and analysis Specific comments: Keywords- it is better to add Botswana, than repetitions We have added Botswana and removed repetitions (Low Resource settings and Sub Saharan Africa) as suggested. Competing interest – delete he/the--- Deleted as suggested. ES. Line 1 - resources settings Purposive sampling-not clearly stated and implemented in the methods section. approximately 76 nurse anesthetists and 18 anesthesiologists in public hospitals- the figure is since 2021 but there has been an ongoing residency program All anesthesia providers were contacted and requested to complete the paper form of the study questionnaire sent to the chief of the anesthesia department by courier. Why do you need to use a courier when there are electronic data collection options? We have rephrased this section to make it clear, as follows: “All anesthesia providers from selected hospitals were contacted and requested to complete the paper form of the study questionnaire sent to the chief of the anesthesia department by courier.” We decided to use courier and paper forms to minimize the risk of low response rate due to lack of familiarity in completing electronic survey or excluding some participants without access to internet. A purposive sampling method of public hospitals was used to achieve representation of different hospital levels across the Botswana health system- however, most of the participant was from Prince Marina Hospital (PMH)- 23 (60.5). Many participants came from PMH because it is the major hospital with a bigger number of anesthesia providers. Also, the research team works at PMH and had more access to participants which may have led to higher response rate. However, we believe that the data collected across all sites provides an appropriate representation of the current practice of regional anesthesia in public hospital in Botswana. Result section Table 1. N=38 It is good to mention the numerical value and then the percentage in a bracket Age total=37 where is the remaining 1 There is a missing information from one participant. However, we have removed this information from the table as suggested below. Prince Marina Hospital (PMH)- 23 (60.5) of the study participant were from a single hospital and how the figures in this study will be inferred from the practice of regional anesthesia in Botswana. PMH has more anesthesia providers as the major hospital in Botswana. Other smaller hospitals had enough representation based on their staffing capacity which could have been as low as one or two anesthesia providers. We believe that the low number of participants from smaller hospitals is an issue of shortage of staff of those hospitals and not a problem of low response rate; therefore, we can trust the results to represent the current practice in those hospitals. It is also an opportunity to highlight a severe shortage of anesthesia providers in smaller hospitals in Botswana. What is the essence of investigating the sociodemographic status of anesthesia providers unless it has a statistical analysis in association with the practice We have removed this information from the table as suggested. We have kept 3 characteristics of participants relevant to regional anesthesia practice (qualification, Hospital level, and experience). Table 2. Regional anesthesia capacity (anesthesia providers, procedures, equipment, supplies, and drugs) for public hospitals in Botswana How do we know the specific practice is not performed either due to a lack of knowledge and skills or basic essential equipment for each regional anesthesia technique? Thank you for your comment. The purpose of this table was to describe the current situation in practicing regional anesthesia in public hospitals in Botswana. The reasons of not practicing some techniques were addressed in Table 4. Table 3: N= 38 Regarding the technique of block, what do “N-37” and “%” implies? A single anesthesia provider can use three of the approaches mentioned and the figure depicted in the table needs elaboration. The same is true for the rest of the sub-topics in the table. We have added some explanation below the table as follows: For the following variables: technique, indication, surgical procedure, RA training, use of and guidelines; one participant could choose multiple answers and therefore the total response for each choice/answer is 38 (for each question, the number of responses reflects the number of participants with the experience with the concerned option). For other variables (frequency and satisfaction), participants had to choose one option and therefore the total number of responses is 38 for all options. RA-training- Only 24 (63.1) have formal training at the University or a short course in regional anesthesia but all the study participants can at least perform spinal anesthesia. Is that possible to practice without any training, how is the standard of practice negotiated here? We have corrected the variable for more clarification as follows: RA training (other than spinal). The question was about regional anaesthesia training excluding spinal anaesthesia because every anaesthesia provider in Botswana had good training in performing spinal anaesthesia. However, other regional anaesthesia techniques are not taught either because of lack of resources and trainers (for physician anaesthesiologists) or because they are not part of the curriculum and scope of practice for nurse anaesthetists. Table 4: It would have been good thematically analyze the challenges in terms of academic qualification, institution, and year of experience … with its mitigation strategies Thank you for your comment. As this question was asked as free text, we tried to capture common answers which were given by all groups of participants. We have modified the table to provide a systematic analysis at 3 levels (individual, organization, and patient). Discussion and conclusions: Those are elaborations of the whole study with other similar studies and the findings. Hence, the discussion shall be revised based on the feedback raised in the methods and result section. It needs to be revised and needs to be very clear about what this adds to the existing literature and clearly details learning points. Thank you for your comment. We have added a paragraph to explain what this manuscript adds to the current literature, as follows: “There is paucity of data on current regional anesthesia practice in Botswana and other low- and middle-income countries especially in Sub Saharan Africa. This study is a great contribution to the existing literature on understanding the regional anesthesia practice in LRS towards access to safe anesthesia and surgery. The results highlight the lack of local training capacity, lack of equipment and supplies, and inadequate administration support as major barriers to the delivery of regional anesthesia services in Botswana. This article can be used for advocacy for more investments for safe regional anesthesia programs in Botswana and other LRS.” Overall needs a further major revision of the methodology, English grammar, and syntax to write in a scientific voice fashion and the journal protocols. Thank you for your feedback. We have improved the methodology and scientific writing as suggested. We believe that our manuscript has been improved to meet the publication requirements of Plos One. Reviewer #2: Dear authors, here you receive my remarks concerning the manuscript entitled “Regional anaesthesia practice in public hospitals in Botswana: A cross-sectional study” and Short Title: Regional anaesthesia practice in public hospitals in Botswana with number PONE-D-23-09813. The authors present an observational study and show the results of cross-sectional survey among anesthesia providers working in public hospitals in Botswana. The article is well written and provides a clear cut idea and simple statistics. A number approval of the medical ethical board is provided. I think that it is an interesting manuscript and important for the situation in Botswana concerning the daily practice in regional anesthesia. Thank you for your feedback. I have a few remarks: Abstract: (Results)… by a small number of participants one referral hospital. Please change into:…by a small number of participants in one referral hospital. We have changed this as suggested. P5 Setting of the study. Is it possible to provide some more information about the greater perspective, i.e. how many anesthesia providers are there in total? You mention about 76 nurse anesthetists and 18 anesthesiologists. Am I correct that you received only from 4 anesthesiologists an answer concerning the survey? How many hospitals are there actually? You mention 25 (Figure 2)! It would improve understanding to actually relate your results in the greater perspective of the total and in what way it is the best representing sample provided here? We have added more details to provide greater perspective as suggested: During the study period, there was a shortage of surgical and anaesthesia workforce in Botswana with 76 nurse anaesthetists, less than 20 clinical officers, and 18 anaesthesiologists19. Anaesthesiologists work mainly in two public hospitals (Prince Marina Hospital (PMH) and Francis Town). District hospitals are staffed by medical officers and nurse anaesthetists while primary hospitals are staffed only by nurse anaesthetists. P13 Can you tell us in how many of the cases locoregional anesthesia was used in relation of the number that could have been performed and was chosen to perform general anesthesia due to the reasons mentioned in Table 4, with of course the exclusion of the patients who did not choose locoregional anesthesia? In other words, is it possible for instance to calculate how many women in labour received general anesthesia and could have received spinal anesthesia but due to the reasons presented in Table 4 this did not happen. This is only easy one example, there may be more. Thank you for your comment. We don’t have this information because the main objective of the study was to evaluate the capacity of the anesthesia providers and their hospitals in delivering regional anesthesia services without getting more details on the actual care of individual patients. This may be addressed by follow up studies. However, there is a previous study done by Kassa and colleagues in 2017, on types of anesthesia for cesarean section (CS) in Botswana, which showed that most CS were done under spinal anesthesia (at a rate of 95.2%) (see this article: Kassa MW, Mkubwa JJ, Shifa JZ, Agizew TB. Type of anaesthesia for caesarean section and failure rate in Princess Marina hospital, Botswana’s largest referral hospital. Afr Health Sci.2020;20(3):1229-1236. doi:10.4314/ahs.v20i3.26). Regarding Table 4: Did you become aware of shortage also to treat possible Local anesthetic systemic toxicity (LAST). Any idea about the incidence and the outcome of this serious complication? Thank you for your comment. We don’t have this information. We corrected data on the availability of the protocols to manage LAST. The incidence of LAST can be addressed by follow up studies. Textual: Do you mean “limited resources settings" or limited resource settings? Please compare when searching in the internet? We have corrected this to low resource settings after checking in the literature. Reference double! Ref 13= ref23 We have corrected the reference as suggested and kept reference 13. Attachments Attachment Submitted filename: Reviewers_Responses letter_05 July.docx https://doi.org/10.1371/journal.pone.0295932.r002
23 Oct 2023 Decision Letter - Silvia Fiorelli, Editor PONE-D-23-09813R1Regional anaesthesia practice in public hospitals in Botswana: A cross-sectional studyPLOS ONE Dear Dr. Tuyishime, 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. ============================== ACADEMIC EDITOR: Please carefully assess all reviewer's comments============================== Please submit your revised manuscript by Dec 07 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, Silvia Fiorelli 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. [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 #1: All comments have been addressed Reviewer #2: All comments have been addressed ******** 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: N/A ****** 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 ****** 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: Sorry for the inconveniences and delay in the publication process. Despite limitations on methodological robustness the authors tried their best to incorporate the given feedback, the research work is imperative, informative and gives insight for policymakers ,funding agencies and professional development . Hence, I suggest the acceptance of the manuscript with minor revisions. Reviewer #2: Dear authors, here you receive my 2nd review regarding the manuscript with the title: Regional anaesthesia practice in public hospitals in Botswana: A cross-sectional study (Regional anaesthesia practice in public hospitals in Botswana) and Manuscript Number: PONE-D-23-09813R1. The authors have carefully edited the manuscript and taken our previous criticisms seriously to improve understanding and clarity of the article and have answered our questions accordingly. I only have one text comment. Please look at the Plos One’s Style requirements more carefully and accurately as requested by the Academic Editor (Silvia Fiorelli). There should be uniformity in the way references are numbered in the text, ie with or without a space after the last letter of a word, with or without brackets, or as a superscript. See examples on the following pages: page 5: … guidelines(17). And more examples on this page and further on this page and in the manuscript page 6: … hospital(15,21) and line 4: …training 15 and in the discussion on P13 : … women 3-5 and page 14: .. program (3-6) or …LRS (3-6, 12,13) Please check other places within the article also? ****** 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: Yes: p.bruins ******** [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.0295932.r003
Revision 2
28 Oct 2023 Author Response Eugene TUYISHIME, MBBS, MSc, 28th October, 2023 Anesthesiologist Assistant Program Director, Anesthesia and Critical Care department University of Botswana, Phone: + 26774504984 Email: tuyishime36@gmail.com To: Editor of Plos One Journal Dear Editor, Silvia Fiorelli, RE: Re-submission of the manuscript/PONE-D-23-09813 entitled “Regional anaesthesia practice in public hospitals in Botswana: A cross-sectional study” I am pleased to submit a revised version of our study to Plos One journal. Our responses to your comments and the reviewer’s questions are highlighted in text in blue both in this letter and the manuscript text. Thank you for your consideration. Sincerely, Dr Eugene Tuyishime Editor and Reviewer Comments:   Academic Editor (Silvia Fiorelli) Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. 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 We have addressed the style requirements as suggested. Reviewer #1: Sorry for the inconveniences and delay in the publication process. Despite limitations on methodological robustness the authors tried their best to incorporate the given feedback, the research work is imperative, informative and gives insight for policymakers, funding agencies and professional development. Hence, I suggest the acceptance of the manuscript with minor revisions. Thank you for your feedback and suggestions throughout the review process. Reviewer #2: Dear authors, Here you receive my 2nd review regarding the manuscript with the title: Regional anaesthesia practice in public hospitals in Botswana: A cross-sectional study (Regional anaesthesia practice in public hospitals in Botswana) and Manuscript Number: PONE-D-23-09813R1. The authors have carefully edited the manuscript and taken our previous criticisms seriously to improve understanding and clarity of the article and have answered our questions accordingly. I only have one text comment. Please look at the Plos One’s Style requirements more carefully and accurately as requested by the Academic Editor (Silvia Fiorelli). There should be uniformity in the way references are numbered in the text, ie with or without a space after the last letter of a word, with or without brackets, or as a superscript. See examples on the following pages: page 5: … guidelines(17). And more examples on this page and further on this page and in the manuscript page 6: … hospital(15,21) and line 4: …training 15 and in the discussion on P13 : … women 3-5 and page 14: .. program (3-6) or …LRS (3-6, 12,13) Please check other places within the article also? Thank you for your feedback. We have addressed the style requirements throughout the manuscript as suggested. Attachments Attachment Submitted filename: Reviewers_Responses letter_28 Oct.docx https://doi.org/10.1371/journal.pone.0295932.r004
4 Dec 2023 Decision Letter - Silvia Fiorelli, Editor Regional anaesthesia practice in public hospitals in Botswana: A cross-sectional study PONE-D-23-09813R2 Dear Dr. Tuyishime, 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, Silvia Fiorelli Academic Editor PLOS ONE Additional Editor Comments (optional): Congratulations to the authors and thanks to the reviewers for the provided suggestions which really helped improve the quality of the manuscript 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 ******** 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 ****** 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: The Authors revised all the feedbacks meticulously. Hence, from my perspective, it is reasonable to give green light for full consideration of publication. Reviewer #2: Dear authors, here you receive my 3 rd review regarding the manuscript with the title: Regional anaesthesia practice in public hospitals in Botswana: A cross-sectional study (Regional anaesthesia practice in public hospitals in Botswana) and Manuscript Number: PONE-D-23-09813R2. The authors have again carefully edited the manuscript and taken our previous criticisms seriously to improve understanding and clarity of the article and have answered our questions accordingly. Finally, The authors have taken the criticism to heart and adapted the texts and references to the proposed Plos one’s house style. I have no further comment. ****** 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 ******** https://doi.org/10.1371/journal.pone.0295932.r005
Formally Accepted
7 Dec 2023 Acceptance Letter - Silvia Fiorelli, Editor PONE-D-23-09813R2 Regional anaesthesia practice in public hospitals in Botswana: A cross-sectional study Dear Dr. Tuyishime: 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 customercare@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. Silvia Fiorelli Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0295932.r006

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .