Round 1

Reviewer 1 Report

Bitan and coauthors reported the research about examining the effect of a suggested Personal Protective Equipment (PPE) wearing protocol (gown protocol) on shortening pre-hospital treatment times compared to the current coverall protocol. They revealed that donning times and heart rates were significantly lower in the gown protocol compared to the standard coverall protocol. And shortening the time until providing primary medical care, higher comfort levels, less difficulty in providing medical care, and lower heart rate values are advantages in using the gown protocol over the coverall protocol. This research is meaningful and informative. Therefore, I recommend the paper be accepted by Applied Sciences after addressing the following issues in a minor revision.

1. The authors should clarify the meaning of the two lines in Figure 3.

2. What do the numbers on the x axis mean in Figure 5,6,7? The authors should explain it in the caption of the figures.

3. The authors should correct the typos in the manuscript. For example, on page 1, line 30: “Doning” should be “Donning”. On page 1, line 32: “comforatble” should be “comfortable”.

4. The authors should double check the format of the references. For example, ref. 5 and 23.

Author Response

Response to Reviewer 1 Comments

We thank the reviewer for the care taken in reviewing our manuscript and for the suggestions for improving it. Here is our point-by-point response:

Point 1: The authors should clarify the meaning of the two lines in Figure 3.

Response 1: Thank you for the important comment. By performing the correlation analysis, we aim to visualize the differences between the time measurements of the two protocols. We wanted to allow the reader to notice that for most participants, time measurements of the gown protocol were shorter than the coverall. We changed the title and the explanation on page 7.

Point 2: What do the numbers on the x axis mean in Figure 5,6,7? The authors should explain it in the caption of the figures.

Response 2: In the Results section, Figure 5 and Figure 6 (on page 9) and Figure 7 (on page 10), we added axis titles that explain the meaning of the numbers on the x axis.

Point 3: The authors should correct the typos in the manuscript. For example, on page 1, line 30: “Doning” should be “Donning”. On page 1, line 32: “comforatble” should be “comfortable”.

Response 3: We corrected the mentioned typos (page 1, line 30: “Doning” to “Donning”. On page 1, line 32: “comforatble” to “comfortable”) and performed a proofread to the entire manuscript.

Point 4: The authors should double check the format of the references. For example, ref. 5 and 23.

Response 4: We double checked the format of the references and corrected the format of the references #5, #6 and #10 on page 14, and #23 on page 16.

Reviewer 2 Report

I appreciated having the opportunity to review this manuscript. This study compared two personal protective equipment wearing protocols in terms of short time to treatment in pre-hospital settings. I have some comments and suggestions: 

1. "Power Sample Size software" need to be specified with details. For example, software name, version, and company.

2. "at a significance level of 0.05 and an intensity of 0.8" is repeated twice in Section 2.2.

3. The method to investigate the order effect is not described clearly. Which measurements were used to investigate it? How did they work to show if there was an order effect on the performance?

4. Table 1 can be improved and simplified by only listing mean+/-SD and median (min-max) for quantitative variables, frequency (percentage) for qualitative variables. In addition, the title should be placed above the table.

5. In sections 3.1-3.2, it is better to provide both mean and SD in the text with the format of mean +/-SD sec for both protocols.

6. The purpose of correlation analysis (shown in Figure 3) is not clear to the readers, especially without any explanation in the text. Please explain why conducted this analysis. If the authors would like to compare the time between two protocols, t test (or Mann-Whitney U test) or agreement analysis are appropriate. If the authors would like to show the time for each participants, the plot is ok, but x and y axis label should be equal spaced.

7. Figures 5-6 need indicators for ratings 1-7. For example, 1 indicates easy, 7 indicates difficult.

8. In line 221, there is typo in correlation. After showing two correlations, it is better to explain it from the clinical prospective.

9. In lines 234-237, it is better to provide the correlation r values, so readers can know the direction of correlation. 

10. In line 252, calculation is not correct for minutes. Please correct them.

11. Discussion section should not be mixed with results, it should only focus on the discussion of this study. Some results in the Discussion section should be removed to Results section or deleted if repeated. For example, exact correlation and p values. 

Author Response

Response to Reviewer 2 Comments

We thank the reviewer for the care taken in reviewing our manuscript and for the suggestions for improving it. Here is our point-by-point response:

Point 1: "Power Sample Size software" need to be specified with details. For example, software name, version, and company.

Response 1: In page 4, lines 128-130, we added information on "PS: Power Sample Size Calculation ", including the source and a link to the tool.

Point 2: "at a significance level of 0.05 and an intensity of 0.8" is repeated twice in Section 2.2.

Response 2: In page 4, section 2.2, line 134, we removed "at a significance level of 0.05 and an intensity of 0.8" that was repeated twice.

Point 3: The method to investigate the order effect is not described clearly. Which measurements were used to investigate it? How did they work to show if there was an order effect on the performance?

Response 3: To investigate the order effect, we performed Wilcoxon test to check if there is a significant difference between the first and the second measurement for each participant. There was no statistically significant difference between the measurements (p=0.706), which implies that the order did not influence the time measurements. We added an explanation in page 6, section 3.1, lines 175-177.

Point 4: Table 1 can be improved and simplified by only listing mean+/-SD and median (min-max) for quantitative variables, frequency (percentage) for qualitative variables. In addition, the title should be placed above the table.

Response 4: We changed the wording and the way we present the information in the Main indices’ column in Table 1 (page 6) - mean+/-SD and median (min-max) for quantitative variables, frequency (percentage) for qualitative variables.

Point 5: In sections 3.1-3.2, it is better to provide both mean and SD in the text with the format of mean +/-SD sec for both protocols.

Response 5: We added the missing information, reporting both mean and SD in section 3.1 (lines 177-179) and section 3.2 (lines 194-195), pages 6-8.

Point 6: The purpose of correlation analysis (shown in Figure 3) is not clear to the readers, especially without any explanation in the text. Please explain why conducted this analysis. If the authors would like to compare the time between two protocols, t test (or Mann-Whitney U test) or agreement analysis are appropriate. If the authors would like to show the time for each participants, the plot is ok, but x and y axis label should be equal spaced.

Response 6: Thank you for the important comment. By performing the correlation analysis, we aim to visualize the differences between the time measurements of the two protocols. We wanted to allow the reader to notice that for most participants, time measurements of the gown protocol were shorter than the coverall. We changed the x and y axis so they would be equally spaced (Figure 3, page 7).

Point 7: Figures 5-6 need indicators for ratings 1-7. For example, 1 indicates easy, 7 indicates difficult.

Response 7: In the Results section, Figure 5 and Figure 6 (on page 9) and Figure 7 (on page 10), we added axis titles that explain the meaning of the numbers on the x axis.  

Point 8: In line 221, there is typo in correlation. After showing two correlations, it is better to explain it from the clinical prospective.

Response 8: Thank you for your comment. As section 3.4 is part of the Results section, we choose to include the clinical prospective in the Discussion section, and we added this explanation in 4.3.2 section, lines 322-340. In addition, we elaborated and provided additional information on the background variables examined in the research, to make it easier for the readers.

Point 9: In lines 234-237, it is better to provide the correlation r values, so readers can know the direction of correlation.

Response 9: We added the r value correlations as recommended, page 10, section 3.5, lines 236-245.

Point 10: In line 252, calculation is not correct for minutes. Please correct them.

Response 10: We corrected the calculation for minutes as recommended, page 10, section 4.1, line 258.

Point 11: Discussion section should not be mixed with results, it should only focus on the discussion of this study. Some results in the Discussion section should be removed to Results section or deleted if repeated. For example, exact correlation and p values.

Response 11: Thank you for your comment. We removed the results from the discussion section, the exact correlation and p values were deleted. All the results appear in the results section, pages 4-11, sections 3.1-3.5. In addition, we edited the discussion section so it will focus on the discussion.  

Reviewer 3 Report

This is an interesting paper and provides practical improvements for efficient delivery of medical procedures supported by evidence from volunteers undertaking simulation-based trials. In a clinically critical situation such as administration of acute medication there is always a balance of patient outcome with healthcare worker safety. While this study provides some information, and there is some discussion about, and acknowledgement of, the limitations of the study, I feel that the statement at lines 376 to 377 recommending follow up work could be expanded on in detail. 

This study feels like a missed opportunity to look into some of those limitations during the simulation.  For example, as well as perceived level of protection why not have explored actual level of protection?  This would have been easily achieved by putting glo gel fluorescent dye (routinely used to train healthcare staff in safe removal of contaminated gloves) onto the manikin (note the convention in simulation studies is to use that spelling) to see where the volunteer got contamination on their PPE, whether it breached the PPE, and whether they cross contaminated themselves taking it off (it is much more difficult to remove coveralls than gowns). Personal protection does not stop at what is worn, but how the full ensemble works interactively and how easy it is to remove without cross contamination.

Were the volunteers generally more comfortable wearing gowns, which is more routine for a healthcare worker, than coveralls?  This could affect results. Against that, the level of protection afforded by coveralls is more practical in emergency/ ambulance work (so if they were full time paramedics they might wear coveralls more routinely) because they stay intact whereas gowns may be pulled to one side - for example if handling a patient, especially a patient who might be fitting or otherwise moving erratically, or lying in an awkward position etc.  Also, why didn't you get the volunteers to carry a bag of equipment (line 264) for a while before doing the simulation for more realism?

I appreciate after the exercise there is not the opportunity to go back and repeat, adding in these elements, but I think it would add value to the paper to explore them in the discussion.

Author Response

Response to Reviewer 3 Comments

We thank the reviewer for the care taken in reviewing our manuscript and for the suggestions for improving it. Here is our point-by-point response:

Point 1: While this study provides some information, and there is some discussion about, and acknowledgement of, the limitations of the study, I feel that the statement at lines 376 to 377 recommending follow up work could be expanded on in detail.

Response 1: Thank you for this comment. We elaborate the discussion on the study limitation, adding a new Limitations section (4.3.5, on page 13). Specifically the statement in lines 390 to 392 is based on the fact that our knowledge about COVID-19 changed since the beginning of the pandemic. When our research was planned and conducted, the COVID-19 virus was thought to be transmitted by touching infected surfaces, but today we know that it is not true. For this reason we assumed that there is an option that the safety perception has been changed and it would be interesting to study it.       

Point 2: Why not have explored actual level of protection?.

Response 2: Thank you for the idea of using glo gel fluorescent dye to examine the level of protection. This is something we will consider as a future research method. The current study didn't focus on the level of protection, because we wished to focus on the technical and the procedural aspects of donning PPE to first treatment providing times. This allows us to suggest a way to shorten the time until the patient receives emergency treatment in a pre-hospital setting.      

Point 3: Were the volunteers generally more comfortable wearing gowns, which is more routine for a healthcare worker, than coveralls?

Response 3: All our volunteers graded the gown protocol as more comfortable than the coverall protocol. The volunteers’ comfort perceptions are presented and explained on page 8, section 3.3 and page 11 section 4.3.1 . Israeli EMS personnel routinely use the coverall. We examined the relationship between comfort perception and time measurement and found a significant relationship between the two. Those results match the literature review on this subject.    

Point 4: Why didn't you get the volunteers to carry a bag of equipment (line 264) for a while before doing the simulation for more realism?

Response 4: Thank you for this comment. We wanted the volunteers to perform an exercise before doing the simulation so the research would demonstrate the reality better, but we had technical limitations that didn't allow us to perform it. In addition, we conducted the research while COVID-19 pandemic was ongoing in Israel and our ability to perform the research was limited due to lockdowns. We added reference to this subject in the discussion, section 3.5 on page 10.   

Round 2

Reviewer 3 Report

Thanks to the authors for addressing previous comments and recommendations. Those have now been dealt with to my satisfaction.