From hospital to home: A heightened window of vulnerability post-critical illness

Amanda Fuchsia Howard; Kelsey Lynch; Sally Thorne; Leanne M. Currie; Rakesh C. Arora; Robert C. McDermid; Omar Ahmad; Sarah Crowe; Sybil Hoiss; Anita David; Joanne Chu; Alice Erchov; Brianna Hou; Arnima Singh; Miki Tsui; Gregory Haljan

doi:10.1371/journal.pone.0334092

Peer Review History

Original SubmissionNovember 12, 2024
23 May 2025 Decision Letter - Allen Ugargol, Editor PONE-D-24-49915From hospital to home: A heightened window of vulnerability post-critical illnessPLOS ONE Dear Dr. Howard, 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 ensure you respond to and address the queries, changes, comments and suggestions offered by the reviewers. Please submit your revised manuscript by Jul 07 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. 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Additional Editor Comments: Dear Authors, I have received review feedback from both reviewers. Based on the reviewers comments and my own assessment, I am offering you the decision of 'minor revision' for this manuscript and encourage you to comply with the queries, comments and suggestions of the reviewers. Please find attached the reviewers comments and suggestions. [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: N/A Reviewer #2: N/A ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: No Reviewer #2: No ****** 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: The manuscript presents a qualitative interpretive descriptive study focusing on the challenges faced by patients and family caregivers during the transition from hospital to home following critical care. By examining the physical, emotional, and logistical difficulties encountered during this critical recovery period, the study addresses an important gap in post-ICU care and offers insights that could inform the development of more effective models of transitional care and support systems for survivors and their families. Below are specific points to consider for enhancing the manuscript: 1) In order to further emphasize the originality of the work, it would be beneficial if the extent to which the results go beyond the existing literature were made clearer (e.g., inclusion of patient and provider perspectives) 2) It could be helpful to explicitly describe how potential biases (e.g., those arising from participant selection or the influence of team discussions) were minimized to further strengthen the interpretative authority of the findings. For instance, how were participants selected? Was the selection process random? How was it ensured that only "dissatisfied" individuals did not disproportionately participate in the interviews? Alternatively, this could be acknowledged as a limitation of the study. 3) However, it would be helpful to explore in greater detail how the pandemic may have influenced the participants' experiences. Were the challenges described exacerbated by the pandemic, or do they reflect broader systemic issues? Reviewer #2: This is a qualitative study exploring key challenges and issues for patients and carers of critical care survivors, focussing on the transition of care between hospital and home. The methodology is robust and described in detail. The authors used a pragmatic qualitative approach to analysis, which was embedded in the real word experience of people. The methods are described in detail. The analytic method was iterative and driven by the desire to understand and describe the issues from the patient/relative perspective. The presentation of results is detailed but well presented. Th derivation of the key themes and sub-themes are well-supported by quotes. The authors note they considered reflexivity, and also used early cases t adapt information gathering and enquiry. I enjoyed reading this article. It is to some extent context specific, which is reflected on by the authors in terms of grounding in the BC healthcare system. The findings are somewhat shocking, but not discordant with other literature. The results are summarised nicely in the graphic. The discussion is detailed and appropriate in terms of strengths and weaknesses, and provides detailed discussion in context of existing literature. The implications generally, and especially locally, are well-presented. I only have a few suggestions and queries 1. The authors mention purposive sampling of ICU survivors, but not what they meant by this. Did they employ a framework against patient characteristics etc? More detail would be useful. 2. I was unclear how this analysis of their data was framed in a larger study? Can more information about this be presented. It was not clear if this was the primary purpose of the study, or whether this is a secondary question analysed from the interviews. 3. It would be interesting and useful to note the background and experience of the four person analyst group. Were they clinicians, for example? How did this relate to the reflexivity and exploration of potential analyst bias etc? 4. The authors note that patients were involved in the study, including in the eview and development of the emerging themes. However, it is not clear how they were involved at different stages. Can more information be provided, for example in a specific section about patient involvement? ****** 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: Timothy S Walsh ******** [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. 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Revision 1
17 Jun 2025 Author Response Response to Reviewers We thank the editor and reviewers for their thoughtful comments and suggestions for revising our manuscript. We have revised our manuscript accordingly, with our responses and revisions described below. Reviewer #1: The manuscript presents a qualitative interpretive descriptive study focusing on the challenges faced by patients and family caregivers during the transition from hospital to home following critical care. By examining the physical, emotional, and logistical difficulties encountered during this critical recovery period, the study addresses an important gap in post-ICU care and offers insights that could inform the development of more effective models of transitional care and support systems for survivors and their families. Below are specific points to consider for enhancing the manuscript: 1) In order to further emphasize the originality of the work, it would be beneficial if the extent to which the results go beyond the existing literature were made clearer (e.g., inclusion of patient and provider perspectives) • Response: Throughout the discussion we added language to make it more explicit where our findings were novel or unique when compared to existing literature. • In the strengths/limitations section (page 38) we also added 2 sentences relevant to the inclusion of patient, family caregiver, and clinicians as research team members. 2) It could be helpful to explicitly describe how potential biases (e.g., those arising from participant selection or the influence of team discussions) were minimized to further strengthen the interpretative authority of the findings. For instance, how were participants selected? Was the selection process random? How was it ensured that only "dissatisfied" individuals did not disproportionately participate in the interviews? Alternatively, this could be acknowledged as a limitation of the study. • Response: In the sampling and recruitment section (page 7), we added detail specific to the purposive approach we used. • Given the nature of purposive recruitment and sampling, we also added the limitation this may have created for the study (page 37). 3) However, it would be helpful to explore in greater detail how the pandemic may have influenced the participants' experiences. Were the challenges described exacerbated by the pandemic, or do they reflect broader systemic issues? • Response: We bolstered the 3rd paragraph of the discussion (page 33, 34) to address these comments more extensively. Reviewer #2 This is a qualitative study exploring key challenges and issues for patients and carers of critical care survivors, focussing on the transition of care between hospital and home. The methodology is robust and described in detail. The authors used a pragmatic qualitative approach to analysis, which was embedded in the real word experience of people. The methods are described in detail. The analytic method was iterative and driven by the desire to understand and describe the issues from the patient/relative perspective. The presentation of results is detailed but well presented. Th derivation of the key themes and sub-themes are well-supported by quotes. The authors note they considered reflexivity, and also used early cases t adapt information gathering and enquiry. I enjoyed reading this article. It is to some extent context specific, which is reflected on by the authors in terms of grounding in the BC healthcare system. The findings are somewhat shocking, but not discordant with other literature. The results are summarised nicely in the graphic. The discussion is detailed and appropriate in terms of strengths and weaknesses, and provides detailed discussion in context of existing literature. The implications generally, and especially locally, are well-presented. I only have a few suggestions and queries 1. The authors mention purposive sampling of ICU survivors, but not what they meant by this. Did they employ a framework against patient characteristics etc? More detail would be useful. • Response: In the sampling and recruitment section (page 7), we added detail specific to the purposive approach we used. • Given the nature of purposive recruitment and sampling, we also added the limitation this may have created for the study (page 37). 2. I was unclear how this analysis of their data was framed in a larger study? Can more information about this be presented. It was not clear if this was the primary purpose of the study, or whether this is a secondary question analysed from the interviews. • Response: We added clarifying language in several places, including the last paragraph of the introduction (page 5, 6), and the beginning of the data collection (page 8) and analysis page 10, 11) sections. 3. It would be interesting and useful to note the background and experience of the four person analyst group. Were they clinicians, for example? How did this relate to the reflexivity and exploration of potential analyst bias etc? • Response: In the data analysis section (page 11, 12) we added details of the smaller analysis group and described interactions with the larger team as it related to reflexivity and potential bias. 4. The authors note that patients were involved in the study, including in the review and development of the emerging themes. However, it is not clear how they were involved at different stages. Can more information be provided, for example in a specific section about patient involvement? • Response: We added a stand-alone paragraph/section to the methods (page12) describing patient partner involvement throughout the study. Attachments Attachment Submitted filename: Response to Reviewers Transition H2H June 4.docx https://doi.org/10.1371/journal.pone.0334092.r002
23 Sep 2025 Decision Letter - Taiwo Opeyemi Aremu, Editor From hospital to home: A heightened window of vulnerability post-critical illness PONE-D-24-49915R1 Dear Dr. Howard, 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, Taiwo Opeyemi Aremu, MD, MPH, PhD Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewer #2: 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 #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 #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? 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 #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 #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 #2: (No Response) ****** 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 #2: Yes: Professor Tim Walsh, Usher Institute, University of Edinburgh ******** https://doi.org/10.1371/journal.pone.0334092.r003
Formally Accepted
Acceptance Letter - Taiwo Opeyemi Aremu, Editor PONE-D-24-49915R1 PLOS ONE Dear Dr. Howard, 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. Taiwo Opeyemi Aremu Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0334092.r004

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