Evaluating acceptability of the Inpatient Mental Health Pharmaceutical Assessment and Care Tool (IMPACT): A multi-site study in the United Kingdom

Fatima Q. Alshaikhmubarak; Richard N. Keers; Petra Brown; Penny J. Lewis

doi:10.1371/journal.pone.0341776

Peer Review History

Original SubmissionJuly 15, 2025
28 Dec 2025 Decision Letter - Yaser Mohammed Al-Worafi, Editor Dear Dr. Alshaikhmubarak, 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 Feb 11 2026 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 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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If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references.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 If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.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: I Don't Know Reviewer #2: N/A ****** 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: The study assessed the acceptability of the IMPACT tool, designed to help UK mental health pharmacy teams identify high-risk inpatients early. Conducted across five NHS sites, it involved pharmacy staff training, retrospective tool use, and feedback via reflection sheets and focus groups. Overall, the tool was well-received—seen as effective and easy to use—though some pharmacy technicians found certain clinical criteria challenging. Feedback led to improvements in the tool and training materials, resulting in a more user-friendly version and a detailed manual. The study concluded that IMPACT was acceptable and called for further research into its feasibility and impact. Could the authors clarify the following points please: 1- Line 129: Which two organisations were selected for the initial presentation, and how does this differ from the training session described in lines 136-138? What is the rationale behind selecting these organisations over the others that participated. 2- Line 187: typing error [name]. 3- Supplementary file 5/page 6: a. What strategies could be used to ensure that missing blood tests are reviewed, and the IMPACT tool will be re-visited if results are not immediately available to ensure patient’s safety. b. Authors refer to how risk indicators are open to interpretations and that clinical judgement could be used to risk stratify patients. Does this apply to pharmacy technicians as well? Would they get any supervision and training required to ensure safe completion and implementation of the tool? 4- Results section: a. The authors mentioned recruitment commenced 25/07/2024-24/01/2025 (lines 131-132) and the interviews were from October 2024 to Feb 2025. Please check that the dates are consistent. b. Did all participants complete the study? Reviewer #2: Overall, the manuscript makes a valuable contribution to the literature on patient prioritization and pharmacy practice in mental health settings. The manuscript is clearly written and methodologically sound. The findings are coherent, well-supported by participant quotations, and offer practical insights relevant to implementation. However, minor clarifications and refinements are required. 1. In Table 3 (Modifications following the first focus group), the original risk indicator “Patients with physical healthcare issues requiring follow-up” was modified to “Patients with physical healthcare issues requiring follow-up by pharmacy team.” Please clarify the rationale for specifying the pharmacy team and explain how risk stratification is influenced by the type of person doing the follow-up required. Specifically, does the risk level differ when follow-up is undertaken by the pharmacy team versus other healthcare professionals (e.g., physicians or nurses)? 2. In Table 3, the combined risk indicator includes “Chronic kidney disease Stage <3b (eGFR 45–59 mL/min)”. This terminology is unclear and not aligned with CKD classification. An eGFR of 45–59 mL/min/1.73 m² corresponds specifically to CKD Stage 3a, rather than “<3b”. I suggest to revise the wording for accuracy and clarity or clearly define the intended stages. 3. Although a formal sample size calculation is not required for qualitative studies, the manuscript would be strengthened by explicitly stating how data saturation (or information power) was considered or judged sufficient across the focus groups and dual interview. 4. Regarding the outcome of the IMPACT tool, I have noticed an overlap between the follow-up intervals for high-risk and moderate-risk patients. Specifically, both categories include a review at every 2 days (high risk: every 1–2 days; moderate risk: every 2–4 days). This overlap may reduce the clarity of risk stratification and follow-up prioritization. 5. In line 187, the statement reads: “Ethical approval was obtained from the University [name] Ethics Committee (19507).” Please specify the full official name of the university and the ethics committee instead of using “[name]”. 6. Please introduce the full term at its first appearance in the Abstract (NHS, line 37) and again at its first appearance in the Introduction (line 68). Thereafter, please use the abbreviation consistently throughout the manuscript. 7. In Table 1, the abbreviation EPMA is used without providing the full term. Please write the full term as a footnote below the table. ****** 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: Dr Gydhia Al-Chalaby 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.] 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.0341776.r001
Revision 1
10 Jan 2026 Author Response #Reviewer 1 Line 129: Which two organisations were selected for the initial presentation, and how does this differ from the training session described in lines 136-138? What is the rationale behind selecting these organisations over the others that participated. The presentation described in line 129 was an introductory session about patient prioritisation and the IMPACT tool and its development. Some organisations chose to deliver this presentation to introduce the IMPACT tool to their pharmacy teams, with the aim of raising awareness of patient prioritisation, highlighting its importance, and increasing engagement and participation in the study. At the end of the presentation, the study was briefly introduced in one slide describing what would be involved in participation. To clarify this, the following sentence was added: “At two organisations, this was preceded by a presentation to pharmacy team members via Microsoft Teams (MS Teams) to introduce the concept of patient prioritisation, development of the IMPACT tool and study and describe what participation would involve.” Line 187: typing error [name]. Thanks for pointing this out, it was corrected. 3- Supplementary file 5/page 6: a. What strategies could be used to ensure that missing blood tests are reviewed, and the IMPACT tool will be re-visited if results are not immediately available to ensure patient’s safety. b. Authors refer to how risk indicators are open to interpretations and that clinical judgement could be used to risk stratify patients. Does this apply to pharmacy technicians as well? Would they get any supervision and training required to ensure safe completion and implementation of the tool? a. Unresolved clinical issues should be clearly noted in the handover and depending on the importance of the results the staff member completing the tool could highlight the person as ‘red’ until the results are reviewed. b. This is a very important point. As described in page 10, pharmacy technicians may require additional training that may vary across organisations due to the wide variation in qualifications and experience. The following sentence was added to supplementary file 5/page 6: “The training session should address the use of clinical judgement, clarifying when it is appropriate to use it and when senior advice or support should be sought.” 4- Results section: a. The authors mentioned recruitment commenced 25/07/2024-24/01/2025 (lines 131-132) and the interviews were from October 2024 to Feb 2025. Please check that the dates are consistent. b. Did all participants complete the study? A. Thank you for highlighting this point. Recruitment and interviews were two distinct phases of the study. Recruitment took place between 25/07/2024 and 24/01/2025. After recruitment, participants attended the training session, started using the IMPACT tool, and completed the reflection sheets. This created a gap between recruitment and interviews which occurred later, between October 2024 and February 2025. B. One participant dropped out after the training session as they struggled to find time to participate. This was added in the results section: “A total of 18 pharmacy staff members consented to participate in this study. One pharmacist dropped out from the study as they struggled to find time to participate.” #Reviewer 2 1. In Table 3 (Modifications following the first focus group), the original risk indicator “Patients with physical healthcare issues requiring follow-up” was modified to “Patients with physical healthcare issues requiring follow-up by pharmacy team.” Please clarify the rationale for specifying the pharmacy team and explain how risk stratification is influenced by the type of person doing the follow-up required. Specifically, does the risk level differ when follow-up is undertaken by the pharmacy team versus other healthcare professionals (e.g., physicians or nurses)? This was suggested by participants, who explained that the purpose of the indicator is to identify patients at risk due to a lack of timely pharmacy review. They argued that this risk only arises when pharmacy input is specifically required. If a patient instead requires review by another healthcare professional, the absence of frequent pharmacy review does not represent a safety risk attributable to the pharmacy team. The following sentence was added to Table 3’s footnote: “Participants suggested this on the basis that the indicator should only flag risk when timely pharmacy input is required”. 2. In Table 3, the combined risk indicator includes “Chronic kidney disease Stage <3b (eGFR 45–59 mL/min)”. This terminology is unclear and not aligned with CKD classification. An eGFR of 45–59 mL/min/1.73 m² corresponds specifically to CKD Stage 3a, rather than “<3b”. I suggest to revise the wording for accuracy and clarity or clearly define the intended stages. • Thank you for noting this very important point. This was clarified to: “Chronic kidney Disease Stage < 3a (eGFR > 45ml/min)” 3. Although a formal sample size calculation is not required for qualitative studies, the manuscript would be strengthened by explicitly stating how data saturation (or information power) was considered or judged sufficient across the focus groups and dual interview. In this study, data collection and analysis occurred concurrently, allowing the research team to assess whether new concepts or perspectives continued to emerge. As data collection progressed, progressively fewer new themes emerged across successive focus groups and the dual interview, suggesting that data saturation had been achieved. The following statement was added to the manuscript: “As data collection progressed, fewer new themes emerged across successive focus groups and the dual interview, with no significant new themes identified in the final data collection, suggesting that data saturation had been achieved.” 4. Regarding the outcome of the IMPACT tool, I have noticed an overlap between the follow-up intervals for high-risk and moderate-risk patients. Specifically, both categories include a review at every 2 days (high risk: every 1–2 days; moderate risk: every 2–4 days). This overlap may reduce the clarity of risk stratification and follow-up prioritization. This is a very important point. The review intervals were developed and agreed upon during the Delphi questionnaire in our previous study and were intentionally defined as suggested intervals. This approach acknowledges that review frequency is likely to vary substantially between organisations due to differences in staffing levels, workload, and service capacity. For example, staff in one organisation may be able to review high-risk patients daily and moderate-risk patients every two days, whereas staff in another organisation may find the longer end of the suggested intervals (e.g. every two days for high-risk patients and every four days for moderate-risk patients) more realistic. Variation may also occur within the same organisation on different days, for instance due to staff absence or increased service demand. The following sentence was added to supplementary file 1 to explain the overlap in the risk: “Note that the appropriate review frequency will vary between and within organisations due to differences in staffing levels, workload, service capacity, and day-to-day operational pressures, which explains the overlap between the proposed ranges.” 5. In line 187, the statement reads: “Ethical approval was obtained from the University [name] Ethics Committee (19507).” Please specify the full official name of the university and the ethics committee instead of using “[name]”. This was added. 6. Please introduce the full term at its first appearance in the Abstract (NHS, line 37) and again at its first appearance in the Introduction (line 68). Thereafter, please use the abbreviation consistently throughout the manuscript. This was added. 7. In Table 1, the abbreviation EPMA is used without providing the full term. Please write the full term as a footnote below the table. Thank you for noting this, the full term was added. Attachments Attachment Submitted filename: Response_to_reviewers.docx https://doi.org/10.1371/journal.pone.0341776.r002
12 Jan 2026 Decision Letter - Yaser Mohammed Al-Worafi, Editor Evaluating Acceptability of the Inpatient Mental Health Pharmaceutical Assessment and Care Tool (IMPACT): a multi-site study in the United Kingdom PONE-D-25-34054R1 Dear Dr. Alshaikhmubarak, 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, Yaser Mohammed Al-Worafi Academic Editor PLOS One Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0341776.r003
Formally Accepted
Acceptance Letter - Yaser Mohammed Al-Worafi, Editor PONE-D-25-34054R1 PLOS One Dear Dr. Alshaikhmubarak, 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 Yaser Mohammed Al-Worafi Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0341776.r004

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