Implementation of point-of-care ultrasound in the medical intensive care unit: A retrospective analysis of physician practices and patient outcomes

Sam Tierney; Stephen Germana; Frank Papik; Werda Alam; Abigail Chua; Sunil Chulani; Karin Hasegawa; Xiaoyue Zhang; Sahar Ahmad

doi:10.1371/journal.pone.0330719

Peer Review History

Original SubmissionMarch 18, 2025
16 Jun 2025 Decision Letter - Afagh Hassanzadeh Rad, Editor Dear Dr. Tierney, 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 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, Hamidreza Badeli 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. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please ensure that your ethics statement is included in your manuscript, as the ethics statement entered into the online submission form will not be published alongside your manuscript. 3. 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? Reviewer #1: Partly Reviewer #2: Partly ******** 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 Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: No Reviewer #2: Yes ****** Reviewer #1: 1. There are inconsistencies in the quality of writing throughout the manuscript. A comprehensive review and editing of English language is necessary to increase the quality and readability of the text, specially in certain parts including the abstract section. For example: "We sought to determine if physician attitudes toward and use of POCUS impact patient outcomes." 2. The literature review done for the paper seems inadequate. A rudimentary search in Pubmed brings a lot of recent studies within the same subject area including RCTs and Cohorts. However, the authors have mentioned a scant few of these studies. A better more robust literature review is warranted with proper citations. NZ 3. The study design tries to merge subjective data with objective outcomes, but raises some questions. How are the cut-offs for stratifications chosen? Is it based on a specific literature or are they chosen arbitrarily? Also the paper does not clarify when the surveys were done? Were they done after the collection of data or during it? 3. Table 1 is reported in the methods section which is odd as it is usually a part of the results. 4. Statistical analysis done on the data needs to be more robust. Heavy reliance on p-value and mean as the only key measures is not acceptable and limits the ability to assess the precision of the estimates. Including confidence intervals and effect sizes would strengthen the reliability of the reported findings. Of course it is understandable that data such as APACHE III score cannot benefit from ES, but other reported outcomes can and should include ES. Reviewer #2: This manuscript explores the relationship between MICU physician use of point-of-care ultrasound (POCUS) and patient outcomes, including ventilator days and MICU length of stay. As a pulmonologist, I appreciate the study's effort to assess whether POCUS, widely accepted as a useful bedside tool, actually translates into measurable clinical benefits. 1.Relying on self-reported physician use introduces a source of bias. it would be helpful to know whether these physicians were formally credentialed or trained in POCUS. 2. The use of appropriate effect sizes can help with better interpretation. Furthermore at least a post hoc power analysis is necessary to determine what this sample size can actually achieve. 3.The use of categorized “high,” “medium,” and “low” implementation and confidence groups is reasonable, but the authors should clarify how the cutoffs were justified. Please justify POCUS stratification thresholds that you have used. 4.Minor grammatical errors are present in the manuscript. A review and revision is necessary. ****** 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 ******** [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.0330719.r001
Revision 1
27 Jul 2025 Author Response We thank you for your thoughtful review of our manuscript, “Implementation of point-of-care ultrasound in the medical intensive care unit: A retrospective analysis of physician practices and patient outcomes”. We value your feedback and the opportunity to contribute to the field’s understanding of the utility of POCUS in the MICU. We have reviewed the reviewers’ comments and have made appropriate edits to the original version of the manuscript as detailed below. We hope that these changes are satisfactory and are to the standards required for publication within PLOS One. 1. ‘There are inconsistencies in the quality of writing throughout the manuscript. A comprehensive review and editing of English language is necessary to increase the quality and readability of the text, specially in certain parts including the abstract section. For example: "We sought to determine if physician attitudes toward and use of POCUS impact patient outcomes."’ ‘Minor grammatical errors are present in the manuscript. A review and revision is necessary.’ We have extensively reviewed and edited the manuscript for grammatical errors and believe that all have been identified and corrected. 2. ‘The literature review done for the paper seems inadequate. A rudimentary search in Pubmed brings a lot of recent studies within the same subject area including RCTs and Cohorts. However, the authors have mentioned a scant few of these studies. A better more robust literature review is warranted with proper citations.’ The majority of literature regarding POCUS use has been focused on its utility as a diagnostic study. As such, there are relatively few high-power studies investigating the impact of POCUS use on endpoints such as length of hospital stay and patient mortality. However, this is an active area of investigation and our literature review has been expanded to reflect this. We have added studies by Kumar et al. (reference 12; manuscript pg 3, lines 25-27), Basmaji et al. (reference 16; manuscript pg 4, lines 8-11), and Tierney et al. (reference 17; manuscript pg 4, lines 11-12) to better reflect the work done in this area to date. 3. ‘The study design tries to merge subjective data with objective outcomes, but raises some questions. How are the cut-offs for stratifications chosen? Is it based on a specific literature or are they chosen arbitrarily? Also the paper does not clarify when the surveys were done? Were they done after the collection of data or during it?’ ‘The use of categorized “high,” “medium,” and “low” implementation and confidence groups is reasonable, but the authors should clarify how the cutoffs were justified. Please justify POCUS stratification thresholds that you have used.’ Thank you for these points, we agree that this section of the manuscript requires clarification. We have updated it accordingly. Physician surveys were administered after data collection was completed (see updated manuscript; pg 5, line 1). In regards to the implementation and confidence groups, cutoffs were chosen to ensure an even distribution of the twelve physicians across the groups (see updated manuscript; pg 5, lines 13-14). 4. ‘Table 1 is reported in the methods section which is odd as it is usually a part of the results.’ Table 1 has been relocated from the Methods section to the Results section. 5. ‘Statistical analysis done on the data needs to be more robust. Heavy reliance on p-value and mean as the only key measures is not acceptable and limits the ability to assess the precision of the estimates. Including confidence intervals and effect sizes would strengthen the reliability of the reported findings. Of course it is understandable that data such as APACHE III score cannot benefit from ES, but other reported outcomes can and should include ES.’ ‘The use of appropriate effect sizes can help with better interpretation. Furthermore at least a post hoc power analysis is necessary to determine what this sample size can actually achieve.’ We have completed additional statistical analysis which has significantly changed the findings of our study and have resulted in large scale edits to the manuscript. We completed a multivariable regression analysis of the data that allowed us to model the relationship between each outcome and physician implementation and confidence groups. This analysis showed a statistically significant increase in MICU length of stay and days spent on mechanical ventilation in the low POCUS confidence group compared to the medium confidence group. This has greatly changed the conclusions of our analysis and the manuscript has been updated throughout accordingly. See updated Methods and Results sections for further detail. In light of these changes, we no longer feel that a post hoc power analysis is indicated. All statistical analysis was performed by dedicated biomedical core statisticians at Stony Brook University. 6. ‘Relying on self-reported physician use introduces a source of bias. It would be helpful to know whether these physicians were formally credentialed or trained in POCUS.’ We agree that our study’s reliance on self-reported physician use introduces a not-insignificant source of bias (discussed on manuscript pg 9, lines 12-13). We further agree that adding additional information about level of POCUS training in the physicians who participated in this study will be worthwhile. We collected this information when the participants were initially interviewed and have added this information to the Supplementary Materials. In addition, we have added a brief discussion of the percentage of physicians across groups who have had formal POCUS training prior to the time period covered by the study (see updated manuscript; pg 7, lines 7-12). Again, we thank you for your assistance in improving our manuscript. We hope that the changes detailed above meet the standards of publication expected by PLOS One. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0330719.r002
6 Aug 2025 Decision Letter - Afagh Hassanzadeh Rad, Editor Implementation of point-of-care ultrasound in the medical intensive care unit: A retrospective analysis of physician practices and patient outcomes PONE-D-25-12695R1 Dear Dr. Tierney, 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. For questions related to billing, please contact billing support . 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, Afagh Hassanzadeh Rad Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0330719.r003
Formally Accepted
Acceptance Letter - Afagh Hassanzadeh Rad, Editor PONE-D-25-12695R1 PLOS ONE Dear Dr. Tierney, 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 Dr. Afagh Hassanzadeh Rad Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0330719.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 .