Redirecting patients from the pediatric emergency department to community locations for care: A qualitative study of healthcare professional and leader perspectives

Erica Qureshi; Quynh Doan; Jessica Moe; Steven P. Miller; Garth Meckler; Brett Burstein; Jehannine (J9) Austin

doi:10.1371/journal.pone.0338725

Peer Review History

Original SubmissionJuly 7, 2025
20 Oct 2025 Decision Letter - Moises Auron, Editor Dear Dr. Qureshi, 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 03 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'. 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We look forward to receiving your revised manuscript. Kind regards, Moises Auron, MD, FAAP, FACP, SFHM, FRCP (Lon), FRCPCH 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 you have indicated that there are restrictions to data sharing for this study. For studies involving human research participant data or other sensitive data, we encourage authors to share de-identified or anonymized data. However, when data cannot be publicly shared for ethical reasons, we allow authors to make their data sets available upon request. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Before we proceed with your manuscript, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., a Research Ethics Committee or Institutional Review Board, etc.). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories. You also have the option of uploading the data as Supporting Information files, but we would recommend depositing data directly to a data repository if possible. Please update your Data Availability statement in the submission form accordingly. 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. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. 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: 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 Reviewer #1: No 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: This article provides great qualitative insight from relevant caregivers/stakeholders about important factors to consider when implementing a program to transition qualifying pediatric patients from the emergency room to a community provider to better address both local staffing/resources and patient experience/quality of care. It presents an important first step to help build a successful program. Not all of the interview data is made available, save for the specific excerpts that are quoted directly in the results portion. I do think this makes sense in the context of this article. However, calling this out would be helpful for the reader to understand why only portions of the responses are being shared or why certain responses are being withheld (was there personal information about the interviewee, was it repetitive or consistent with other opinions?). It would also add value to your analytic section to further explain how you parsed through the interviews for relevant data. I would also understand not providing all the transcripts given these interviews were lengthy and would be a significant amount of data to present in entirety. Perhaps only sharing the 'iterative groupings' rather than complete transcripts as an additional resource would be helpful. The study provided the demographic information (race, gender, education, emergency room connection) for 3 individuals involved in the study (within the methods section). As it is presented, it is not clear why this information is relevant. Reviewer #2: Overall, this was a good study, aiming to demonstrate that there are ways to successfully reduce busy, emergency department volumes for low acuity patients. Although the results of this study were not surprising, it was a good summarization. There may be some bias given the small amount of people that were interviewed The study was very well written and easy to read and to interpret. ****** 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: Noah Schwartz, MD Reviewer #2: Yes: Lauren N. Mientkiewicz ******** [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.] To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation. NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications. https://doi.org/10.1371/journal.pone.0338725.r001
Revision 1
24 Nov 2025 Author Response 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. We have reviewed the style requirements and made edits accordingly to ensure our submission is aligned with the requirements. 2. We note that you have indicated that there are restrictions to data sharing for this study. For studies involving human research participant data or other sensitive data, we encourage authors to share de-identified or anonymized data. However, when data cannot be publicly shared for ethical reasons, we allow authors to make their data sets available upon request. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Before we proceed with your manuscript, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., a Research Ethics Committee or Institutional Review Board, etc.). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. Please update your Data Availability statement in the submission form accordingly. There are ethical restrictions with sharing the data as participants did not consent to have the recorded and transcribed conversations shared. Aligned with Reviewer 1’s feedback below we have shared iterative groupings of additional illustrative quotes in a supporting information file for readers. Additionally, complete data can be requested from the research ethics board that approved this study (our data availability statement in the submission form has been revised to note this). 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. This has been completed. 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. This has been completed, one small grammatical change was made to one citation. 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: No As noted above we have included additional illustrative quotes in a supporting information file and updated our data availability statement. 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 article provides great qualitative insight from relevant caregivers/stakeholders about important factors to consider when implementing a program to transition qualifying pediatric patients from the emergency room to a community provider to better address both local staffing/resources and patient experience/quality of care. It presents an important first step to help build a successful program. Not all of the interview data is made available, save for the specific excerpts that are quoted directly in the results portion. I do think this makes sense in the context of this article. However, calling this out would be helpful for the reader to understand why only portions of the responses are being shared or why certain responses are being withheld (was there personal information about the interviewee, was it repetitive or consistent with other opinions?). We have provided additional information to explain how illustrative quotes were selected in the data analysis section of our methods. Additional quotes would be both lengthy and repetitive as perspectives were consistent. However, for those interested we have included additional illustrative quotes in a supporting information file. It would also add value to your analytic section to further explain how you parsed through the interviews for relevant data. I would also understand not providing all the transcripts given these intermviews were lengthy and would be a significant amount of data to present in entirety. Perhaps only sharing the 'iterative groupings' rather than complete transcripts as an additional resource would be helpful. Thank you for this suggestion, as noted above we do not have participants consent to share the full transcripts and they are quite lengthy. However, we did take this suggestion and have provided iterative groupings of additional illustrative quotes in a supporting information file. The study provided the demographic information (race, gender, education, emergency room connection) for 3 individuals involved in the study (within the methods section). As it is presented, it is not clear why this information is relevant. We have clarified this in our manuscript by moving the positionality statements into a table and explaining that they are provided for the three research team members who supported our data analysis. Given that reflexive thematic analysis involves the researchers as a ‘tool’ in the research process our unique worldview (as shaped by our gender, race, education, emergency room connection) is important to reflect on and disclose. Reviewer #2: Overall, this was a good study, aiming to demonstrate that there are ways to successfully reduce busy, emergency department volumes for low acuity patients. Although the results of this study were not surprising, it was a good summarization. There may be some bias given the small amount of people that were interviewed The study was very well written and easy to read and to interpret. Thank you for this comment. We stopped data collection when we reached theoretical sufficiency (that is when we had enough information to answer our research question in a clinically meaningful way). The goal of this work was not to hear all possible perspectives but instead to gather ‘enough’ to create a visual model that summarized the components of a pediatric redirection program that should be considered before implementation. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0338725.r002
26 Nov 2025 Decision Letter - Moises Auron, Editor Redirecting patients from the pediatric emergency department to community locations for care: A qualitative study of healthcare professional and leader perspectives PONE-D-25-36467R1 Dear Dr. Qureshi, 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, Moises Auron, MD, FAAP, FACP, SFHM, FRCP (Lon), FRCPCH Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0338725.r003
Formally Accepted
Acceptance Letter - Moises Auron, Editor PONE-D-25-36467R1 PLOS ONE Dear Dr. Qureshi, 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. Moises Auron Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0338725.r004

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