Methods for improving the identification of acute stroke during ambulance calls: A scoping review

Areej Almutairi; Fadila Wirawan; Adam Lloyd; Tom Moullaali; Gareth Clegg

doi:10.1371/journal.pone.0327653

Peer Review History

Original SubmissionApril 7, 2025
13 May 2025 Decision Letter - Nik Hisamuddin Nik Ab. Rahman, Editor Dear Dr. Almutairi, 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 Jun 27 2025 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. 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, Nik Hisamuddin Nik Ab. Rahman 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. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section. 3. Thank you for stating the following financial disclosure: “This study was supported by the University of Edinburgh and the King Saud bin Abdulaziz University for Health Sciences. “ Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." If this statement is not correct you must amend it as needed. Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf. 4. We note that Figure 1 in your submission contain copyrighted images. 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 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: 1. 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].” 2. 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. 5. Please remove your figures from within your manuscript file, leaving only the individual TIFF/EPS image files, uploaded separately. These will be automatically included in the reviewers’ PDF. 6. 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. 7. 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. Is the manuscript technically sound, and do the data support the conclusions? Reviewer #1: Partly 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 Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: The study is very vital and highlighted clearly the need for it but will be very essential to report about the gaps in the current practice or difficulties in the current practice with some data. The other improvement, the aim was clear but the term objectives / objective were mentioned in at least three different places but not given importance to list them clearly in the report. Reviewer #2: The authors present the results of a scoping review aimed at exploring methods to improve the identification of acute stroke during emergency calls at ambulance control centers (ACCs), explore current approaches, characterize study types and outcomes, and identify gaps in the literature. The authors identified seven studies examining different methods to improve stroke identification during calls at ACCs. The authors found that improved triage tools reduce time-to-diagnosis and facilitate faster emergency responses, highlighting several methods, including ML-enhanced ASR, targeted training programs, and enhanced triage tools to improve prehospital identification of stroke in ACCs. The study is potentially interesting, but can improved if the following considerations are addressed: 1.Please check and delete the colour sentences in the text (ex: “scene interventions” -page 16, line 4-) 2.In the Introduction section, it is worth adding epidemiological data on acute stroke (see and comment on the study published in Rev Esp Cardiol 2007; 60; 573-580). In this study, the cumulative incidence of cerebrovascular disease per 100,000 population was 218 (95% CI, 214-221) in men and 127 (95% CI, 125-128) in women. 3.Open lines of research include the exploration of methods to improve the identification of stroke versus stroke mimics, stroke versus stroke chameleons, or in subgroups of hemorrhagic versus ischemic stroke etiology, all important and challenging subsets of acute stroke that deserve to be evaluated in further studies. 4.The opinion of the authors on other future lines of research on this topic should be added in the text ****** 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: Ahmed Ibrahim Al Kharusi Reviewer #2: Yes: Adrià Arboix ******** [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 https://doi.org/10.1371/journal.pone.0327653.r001
Revision 1
3 Jun 2025 Author Response Reviewer #1: The study is very vital and highlighted clearly the need for it but will be very essential to report about the gaps in the current practice or difficulties in the current practice with some data. The other improvement, the aim was clear but the term objectives / objective were mentioned in at least three different places but not given importance to list them clearly in the report. Authors: Thank you for your comments. We appreciate your recognition of the relevance and necessity of this study. Regarding your suggestion to elaborate on the gaps or difficulties in current practice, we acknowledge that the existing literature directly focusing on our topic is limited and largely captured within the included studies. To address this, we carefully reviewed the broader but related literature and integrated selected studies to contextualise and build our argument more effectively. We have also added a new reference (lines 29-36) to further support and emphasise the gap we aim to address. We also thank you for your comment on the use of the term “objectives.” Upon revisiting the manuscript, we recognised that “objectives” was used inconsistently and did not add clarity. We have revised the text to consistently use the term “aim”, which better fits the structure and intent of this manuscript. Reviewer #2: The authors present the results of a scoping review aimed at exploring methods to improve the identification of acute stroke during emergency calls at ambulance control centers (ACCs), explore current approaches, characterize study types and outcomes, and identify gaps in the literature. The authors identified seven studies examining different methods to improve stroke identification during calls at ACCs. The authors found that improved triage tools reduce time-to-diagnosis and facilitate faster emergency responses, highlighting several methods, including ML-enhanced ASR, targeted training programs, and enhanced triage tools to improve prehospital identification of stroke in ACCs. The study is potentially interesting, but can improved if the following considerations are addressed: 1.Please check and delete the colour sentences in the text (ex: “scene interventions” -page 16, line 4-) Authors: Thank you for pointing this error out. Because our team regularly review the manuscript, some of the tracked changes were not deleted. We have fixed it, and we decided also to change the term “interventions” to “scenario” because we find it best to suit the sentence's meaning. 2.In the Introduction section, it is worth adding epidemiological data on acute stroke (see and comment on the study published in Rev Esp Cardiol 2007; 60; 573-580). In this study, the cumulative incidence of cerebrovascular disease per 100,000 population was 218 (95% CI, 214-221) in men and 127 (95% CI, 125-128) in women. Authors: Thank you for your comment. We agree that including epidemiological data would strengthen the Introduction section. In response, we revisited our original reference and found that it has been updated with a more recent publication that was released earlier this year. Therefore, we chose to use updated data, which included incidence rates stratified by sex and per 100,000 individuals. These additions have been incorporated into the manuscript text on lines 3–7. We have also updated the reference list (Reference 1). 3.Open lines of research include the exploration of methods to improve the identification of stroke versus stroke mimics, stroke versus stroke chameleons, or in subgroups of hemorrhagic versus ischemic stroke etiology, all important and challenging subsets of acute stroke that deserve to be evaluated in further studies. Authors: Thank you for your comment. Our “Unanswered questions and future research” section addresses diagnostic challenges, such as posterior strokes and variability in performance outcomes across contexts. We appreciate your suggestion to further acknowledge specific stroke subsets, such as mimics and ischaemic vs. haemorrhagic types, which are indeed relevant to the complexity of prehospital stroke identification. Thus, we have revised this section to mention these subgroups and the importance of studying methods that can improve detection across these diagnostic challenges (line 355). 4.The opinion of the authors on other future lines of research on this topic should be added in the text Authors: Thank you for your comment. We agree that the authors opinions can help guide future research directions. In the “Interpretation of the findings” section, we outline our perspective on the implications of the current approaches and highlight areas for further exploration. To clarify our opinion, we have slightly revised the final sentences to directly reflect our team’s recommendations for future research, including the evaluation of real-world integration, standardisation, and implementation challenges (lines 343-346). Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0327653.r002
19 Jun 2025 Decision Letter - Nik Hisamuddin Nik Ab. Rahman, Editor Methods for Improving the Identification of Acute Stroke During Ambulance Calls: A Scoping Review PONE-D-25-18093R1 Dear Areej Almutairi, 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, Nik Hisamuddin Nik Ab. Rahman Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0327653.r003
Formally Accepted
Acceptance Letter - Nik Hisamuddin Nik Ab. Rahman, Editor PONE-D-25-18093R1 PLOS ONE Dear Dr. Almutairi, 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 You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days 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. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. 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 Professor Dr Nik Hisamuddin Nik Ab. Rahman Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0327653.r004

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 .