The impact of the COVID-19 pandemic on the use of restraint and seclusion interventions in Ontario emergency departments: A population-based study

Meghan Weissflog; Soyeon Kim; Natalie Rajack; Nathan J. Kolla

doi:10.1371/journal.pone.0302164

Peer Review History

Original SubmissionSeptember 11, 2023
6 Nov 2023 Decision Letter - Anshuman Mishra, Editor PONE-D-23-28304The impact of the COVID-19 pandemic on the use of restraint and seclusion interventions in Ontario emergency departments: A population-based studyPLOS ONE Dear Dr. Weissflog, 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 Dec 21 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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If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Additional Editor Comments: Article- The impact of the COVID-19 pandemic on the use of restraint and seclusion interventions in Ontario emergency departments by Meghan et al., 2023 explore COVID-related changes in the use of R/S interventions among patients presenting to Ontario emergency departments (EDs) with MH/SU complaints. These results have the potential to inform existing policies to mitigate risks associated with R/S intervention use during future public health emergencies and in general practice. Article is interesting however required few additional explanations- 1. Clear objective, and conclusion about interventions is help to understand the article more about study. 2. Which kind of clinical feature present in MH/SU complaints. 3. What is impact of Clinical segregation of subjects on the results. 4. Graphical representation is important for better representation. 5. What is future prospect of the study. 6. Any comparative study in same region is important to understand the results. 7. What is public health model for other disease situations (epidemic-sporadic etc.) [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: This is an interesting manuscript in which authors have looked into the impact of the COVID-19 pandemic on the use of restraint and seclusion interventions in emergency departments. In particular authors have looked into COVID related changes in the use of R/S interventions in Emergency departments with mental health/Substance use complaints. The study has good sample size, results and conclusions are aligned with the central message. The study adds to the existing knowledge on R/S use during pandemic. Reviewer #2: Overall, this study has the potential to further the understanding of COVID-related changes in the presentation of MH/SU issues in ED facilities, as well as the ways in which the healthcare system responded to these changes during the pandemic and the data from this study can be used to improve the existing policies and procedures related to the use of R/S interventions to minimize the inherent risk to both patients and staff. ****** 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: Amit Kumar Mishra ******** [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: review.docx https://doi.org/10.1371/journal.pone.0302164.r001
Revision 1
21 Feb 2024 Author Response Please find below our responses to the reviewers' comments on our manuscript titled “The impact of the COVID-19 pandemic on the use of restraint and seclusion interventions in Ontario emergency departments: A population-based study” (PONE-D-23-28304), which was submitted to PLOS ONE in September of 2023. I would like to express my gratitude to the reviewers for their constructive feedback, which has been helpful in revising our manuscript. Please find below detailed responses to each of the points raised by the reviewers. 1. Clear objective, and conclusion about interventions is help to understand the article more about study. The reviewers correctly highlighted the importance of a clear objective and conclusion. In response to this, we have revised the manuscript to provide a more focused objective by elaborating on the fact that COVID-related changes in the use of restraint and seclusion interventions can be viewed as an indicator of the broader impact the COVID-19 pandemic had on patient experiences when seeking emergency care [pg. 5, lines 69-76; pg. 7, lines 119-123]. Additionally, we have added a “Future Directions” section to our conclusions to elaborate on avenues for potential intervention that may aid in preventing similar situations during future healthcare crises [pg. 19, lines 352-371]. 2. Which kind of clinical feature present in MH/SU complaints? We appreciate the reviewers' interest in better understanding the clinical features that accompanied presenting MH/SU complaints in the present sample. While the NACRS database does collect information regarding a patient’s specific presenting complaints at the time of intake, this variable is optional in terms of NACRS data reporting guidelines and not consistently reported by participating facilities. As such, it was not possible to obtain robust data regarding specific clinical features that were present at the time of admission, so this variable was not included in the present study. Although the specific symptoms driving patients to seek emergency medical care are not known, attending physicians assign a main problem diagnosis, based on the ICD-10 classification system, to indicate the underlying condition that is most likely responsible for the presenting complaint, taking into consideration a patient’s current symptoms and medical history. Although the limitations of the current dataset prevent us from elaborating on this point, we agree that it is of great importance to further understand not only the impact of COVID-19 on specific symptoms experienced by individuals with MH/SU disorders but also which symptoms were most likely to result in the use of R/S interventions among these patients during the pandemic. To this end, we have added an additional paragraph to “Limitations” section addressing this issue [pg. 19-20, lines 370 -378]. 3. What is impact of Clinical segregation of subjects on the results? The reviewers have highlighted the importance of addressing the impact of clinical segregation on our results. When we examined the impact of COVID-19 on the use of seclusion alone, we observed a similar pattern of effects as that seen in the combined data (restraint and segregation), albeit to a lesser degree. Specifically, the probability of a seclusion event increased from pre-COVID levels by approximately 1% or less across registration month. The increase in probability for main problem diagnosis showed the same pattern as the original results in which diagnostic groups saw the greatest increases in seclusion probability, but to a smaller magnitude (~1-7% increase). These results suggest that the increases in probability seen in the combined data are primarily driven by restraint events more than seclusion events, which is consistent with the fact that there were three times more restraint events reported than seclusion events in 2019 and 2020. In the end, we chose to combine these two categories not only because they are both coercive methods of patient management and are subject to the same mandatory reporting guidelines but also because they generally show a similar pattern of effects when examined separately as they do when combined. 4. Graphical representation is important for better representation. We agree with the reviewer’s comment regarding the importance of graphical representation, and as such, we have added three new figures to the “Results” section to facilitate a better understanding of the data and ensure that readers can interpret the results more effectively [pg. 13-14, line 224, 227, 232; 234-248]. 5. What is future prospect of the study? To address the reviewers' comments regarding the future prospects of the study, we have expanded the discussion to include a “Future Directions” section as described above. This includes exploring additional factors associated with changes in the use of R/S interventions in response to the COVID pandemic and potential intervention strategies to prevent increased use of R/S methods during future healthcare crises [pgs. 19-21, lines 363-398]. 6. Any comparative study in same region is important to understand the results. The reviewers pointed out the importance of including comparable research conducted in the same region. To our knowledge, Martin et al. is the only other study that has looked at COVID-related changes in R/S intervention use in Ontario [described on pg. 5, lines 79-83]. The authors observed a substantial reduction in R/S intervention use, contrary to our findings in the present study. We think that the difference is because their sample was collected over a relatively short period following the onset of COVID, and as such, is not necessarily reflective of the same conditions and systemic strain as was present in Ontario EDs. While there does not appear to be any other comparable research on changes in R/S intervention use in EDs in the same geographical region, a number of studies from around the world have shown similar patterns of increased R/S use despite fewer people accessing care. This is consistent with the fact that COVID-19 was truly a pandemic, and like the virus itself, its impact on health care was not unique or confined to a specific geographical region. To this end, we have updated the “Introduction” section to include several newly published studies on this topic from around the world, the majority of which also found increases in R/S use [pg. 5, lines 83-88; pg. 6, lines 100-109]. 7. What is public health model for other disease situations (epidemic-sporadic etc.)? While we agree that it is important to consider the potential implications of our study's findings for other disease situations, the results of the present study are not as likely to be generalized to different disease scenarios, including epidemics and sporadic situations. While it is not impossible to see similar impacts on the use of R/S interventions given an epidemic of sufficient severity to overwhelm a regional health system, it is unlikely for endemic or sporadic disease events. This is because the driving factor behind the observed R/S increase during COVID was most likely the severe depletion of resources in the Canadian healthcare system, as illustrated by the fact that significant increases in R&S probability were confined to the first wave of the pandemic when the system was least prepared. Importantly, the observed increase in R&S intervention was not unique to COVID-19 or its related symptoms, but instead that its highly infectious nature and potential for severe outcomes resulted in a rapid increase in cases requiring substantial healthcare resources across the entire country (Canada) and more generally the world, in turn overwhelming an unprepared system. This was further exacerbated by the need for strict infection prevention protocols, which further strained already limited resources, both in terms of physical space and health care staff. It should be noted that public health restrictions intended to slow the spread of COVID-19 may have further exacerbated this issue by severely restricting patient access to non-emergency health care services and resources they may have previously accessed to address issues related to mental health and/or substance use concerns. We believe that these revisions have significantly strengthened the manuscript, addressing the reviewers' concerns and improving the overall quality of the paper. We hope that these changes meet the expectations of the reviewers and the editorial board. Thank you for your time and consideration, as well as the opportunity to resubmit our revised manuscript for further evaluation. Attachments Attachment Submitted filename: Response to Reviewers.pdf https://doi.org/10.1371/journal.pone.0302164.r002
28 Mar 2024 Decision Letter - Anshuman Mishra, Editor The impact of the COVID-19 pandemic on the use of restraint and seclusion interventions in Ontario emergency departments: A population-based study PONE-D-23-28304R1 Dear Dr. Weissflog, 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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, 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, Anshuman Mishra, PhD Academic Editor PLOS ONE Additional Editor Comments (optional): Thanks for the revised version. The article is now in shape and defines more appropriately the impact of the COVID-19 pandemic on the use of restraint and seclusion interventions in Ontario. Just one suggestion: please add the country name to the affiliation. Decision- Accepted Reviewers' comments: https://doi.org/10.1371/journal.pone.0302164.r003
Formally Accepted
3 Apr 2024 Acceptance Letter - Anshuman Mishra, Editor PONE-D-23-28304R1 PLOS ONE Dear Dr. Weissflog, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, 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. Anshuman Mishra Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0302164.r004

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