PONE-D-21-08206

Unmet need of essential treatments for critical illness in Malawi

PLOS ONE

Dear Dr. Kayambankadzanja,

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PLOS ONE

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Reviewers' comments:

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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: No

Reviewer #2: Yes

Reviewer #3: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: N/A

Reviewer #3: No

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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: Yes

Reviewer #3: No

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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

Reviewer #3: Yes

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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: In this study, observers gathered data from a convenience sample of 1135 patients. The level of training and uniformity of training of the observers, and equipment used for measurements, are not specified. The data come from two different hospitals but the distribution of these data and the characteristics of the sample are not specified. Out of these 1135, 45 were identified as having an SpO2 <90, 103 a systolic BP < 90, and 17 had a GCS <9. (It's not clear if more than one of these features were seen in some of the patients)The reason for the study was to assess "unmet need" and the reason for looking for this need appears to be for "evaluating the processes of care and to highlight areas for potential quality improvement". The characteristics of these unwell patients are mainly medical, but the characteristics (gender, admitting specialty, age) of the contributing population remains undefined. The outcome in the selected patients is poor, probably worse in the surgical patients (but we are unaware of the outcome of the other possible 970). We don't even know which hospital they came from, or why three collection days were chosen in one hospital and two in the other.

Clearly there are two elements here: diagnosis (not as easy as it might appear, as indicated by citation 3), and then treatment which incorporates many factors: staff provision, their training, facilities, prognosis. It's of interest that there was no "unmet" need in the ICU, for example.

In other countries, this process would be termed "audit": good enough to highlight a problem, but not enough to tell us what to do about it. I suspect that the authors (quite a few, for such a simple data set) could easily have predicted this outcome. There has been a missed opportunity: the question that should be asked next is "why not"? Is there a lack of vigilance, or understanding, or resource?

Were these data anonymised when they were collected? If so, why are the anonymous data not available? If not, how were the data collected and stored?

Reviewer #2: Dr Kayambankadzanja and colleagues report in the what appears to be a point prevalence study on the unmet need of basic interventions in unwell patients in 2 Hospitals in Malawi. The study is in my view very interesting, timely and of value to a broad readership. It highlights the lack of basic interventions in low income, developing world countries and its association with mortality. Sadly patients are commonly very young and extrapolating from this and other data, many lives could potentially be saved and by relatively simple means. The current Pandemic has at times led to the risk of quite basic interventions such as administration of oxygen at sufficient levels being jeopardised in highly developed healthcare systems too, exceptional in the "developed world" yet common place in the developing world.

The paper is well written and concise, maybe a bit too concise.

I have a few comments to make:

As pointed out above, this appears to be a point prevalence study - in the Methods section / Abstract the 2nd sentence "All in patients aged >18 years on single days..." should be changed to the more scientific definition of what type of study this was - point prevalence.

The authors should provide additional basic data such as how many beds the 2 Hospitals have and the ratio of ICU beds to total Hospital beds so that readers get an impression of how scares a resource, monitored and reasonably equipped beds throughout this and many other parts of the world.

It would also be helpful to have a slightly more in detail split of demographics and pathologies of studied groups beyond "surgical, medical and Obs & Gyne? Simple and important information would be % of Trauma patients, number of sepsis, malaria etc.

I appreciate that the authors tried to keep the monitored parameters as relevant and easily measurable/simple as possible, but the additional capture of heart rate, respiratory rate and Temp would have been doable and informative. Given the young age of the studied patients a systolic blood pressure cut off of 90 may be slightly liberal especially if patients had a normal heart rate and were not shocked. Young and fit individuals present frequently with low systolic BP - can the authors comment please.

If additional parameters were not captured, a rationale should be provided in the Methods and possibly also Discussion section of the paper - it would be helpful to mention how other countries and healthcare systems go about managing at risk inpatients - in the UK for example via NEWS and more recently NEWS 2 scoring, other European countries and Australia use EWS too, in the US this is a more novel concept.

In terms of treatment, what is the setup apart from number of ICU beds in the 2 Hospitals studied. Is oxygen readily available and lastly is there a cost factor which has to be considered as well and needs mentioning i.e. are certain interventions not provided unless patients and relatives can pay for them?

Minor comment: Some minor language editing may be helpful for example: First sentence Background in the Abstract: should read "during" rather than in the Covid Pandemic

Reviewer #3: The authors submit a short research letter about critical care needs in Malawi. This is an interesting and important topic. However, I have some concerns about the current version of the manuscript:

1. The abstract should be more specific. Please outline in the background of the abstract and the introduction which vital signs you are investigating as markers of critical care requirements. For readers not familiar with LMIC critical care, it may be worth stating that delivery of O2 or fluid administration represents higher level of care in many hospitals. In the methods you state "The cut-offs for severe vital

70 sign derangements were adopted from previous work in Tanzania and Sweden (4, 7)", please refer to this in the introduction to explain why you used these markers and cut-offs.

2. Were there any differences between the DGH and the large hospital with 4 critical care beds regarding the delivery of care? Would it be possible to determine from the data you have? As mentioned above, it would link to how care is delivered in both settings: Does oxygen therapy and fluid administration happen outside intensive care? Routinely or only if no ICU bed is available? Are patients routinely screened for hypoxia and low blood pressure? If so, how often? Is GCS the routine measure for low GCS? How often is it preformed?

3. In the discussion the authors need to be specific that they have analysed data from two very different hospitals in Malawi. As to whether the lack of care provision is generalisable to other LMIC settings remains unclear. In my experience, there is a very wide variation of the care provided depending on country, localisation (urban vs rural), setup of healthcare system (private versus public, nationwide versus regional governance). These limitations must be mentioned.

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Reviewer #1: Yes: Gordon Drummond

Reviewer #2: No

Reviewer #3: No

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Unmet need of essential treatments for critical illness in Malawi

PONE-D-21-08206R1

Dear Dr. Kayambankadzanja,

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.

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Kind regards,

Tai-Heng Chen, M.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Please make corrections according to Reviewer 3's comments. Afterwards, this manuscript would be completely acceptable.

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 #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

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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 #1: (No Response)

Reviewer #2: Yes

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

Reviewer #2: N/A

Reviewer #3: No

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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 #1: (No Response)

Reviewer #2: Yes

Reviewer #3: No

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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 #1: (No Response)

Reviewer #2: Yes

Reviewer #3: Yes

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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 #1: (No Response)

Reviewer #2: (No Response)

Reviewer #3: Thank you for addressing all comments. It would be nice to see some basic statistics (e. g. Chi square) to compare hospitals. Also, please delete "Or" in line 142. Start the sentence with "There...."

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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

Reviewer #3: No