Review Reports - Evaluation of Delayed Effective Discharge for Non-Medical Reasons in Patients Admitted to Acute Care Hospitals in Spain: A Scoping Review

Round 1

Reviewer 1 Report (Previous Reviewer 1)

Comments and Suggestions for Authors

Dear authors, thank you for the opportunity to read your manuscript.

In this second version is needed to perform the manuscritp according PRISMA-ScR statement.

Keywords: Must adjust to MeSH terms the following terms (Delayed discharges; inappropriate stays'; delayed transfer of care). I suggest: "Patient discharge" instead of "delayed discharge"; I think "Length of saty" is another appropiate keyword; another suggestions: "Transfer Agreeement". I suggest a keyword for the design ("Review").

Abstract: Method needs to be explained in more detail: terms used, eligibility criteria, sources of evidence, charting methods.

Material and methods:

explaining in a structured way (although not necessarily with subheadings) what steps are followed will improve the methodology: elegibility criteria, information sources, search, selection of sources of evidence, data charting process, critical appraissal of individual sources of evidence, synthesis of resuts.

The question guiding the research should be included.

Page 2 (line 79): you must explain the acronym PRISMA (and express it in capital letters).

Page 2 (lines 85-86): the information described in the preceding paragraph is duplicated ("The review was carried out according to JBI methodology [14], and a five-step methodological framework was used for additional support following Arksey and O´Malley criteria [12]").

Page 2 (line 94):Because the terms used are descriptors and free terms, to clarify this issue you must identify those that are controlled language, descriptors (MeSH), and those that are natural language.

In table 1 include each database in separate rows. Cinahl and Medline have used the same search strategy? (the one described in Table 1 looks like cinahl).

Explain this paragraph further: "The search started with a selection of papers according to tittle, summary, and key words by two reviewers acting in parallel and independently and including them in the study once the paper was entirely reviewed. Doubts about the inclusion or exclusion of a paper were solved by consensus of two authors. References of all papers selected were then revised in search of another paper suitable to be included" (Steps according to the PRISMA flowchart: elimination of duplicates, screening by title and abstract, full text screening, snowball search strategy on the references of included studies...).

Results:

Figure 1 is not displayed correctly (it is more appropriate to use the model proposed by PRISMA since you use this methodology in the results report).

In the flowchart, in the identification step does not show the results in each of the databases. How many duplicates were eliminated? Explain better the diagram content in the text.

It would be interesting if the results could be organized and grouped according to types of reasons for delayed discharge. In the conclusions you indicate 3 factors: internal hospital factors, external hospital factors and personal factors (it is correct?).

Try to locate the figures and tables just below the citation in the text.

The following paragraph: As to the study type, one was a systematic review [2] and eight were observational studies, including cross-sectional studies [11,15–21], prospective studies [10,22] and pre- and post-intervention studies [23,24]". In my opinion, the sentence should be linked to the previous paragraph as it explains information from the same table. Improve the content of the table explanation.

In my opinion, it is interesting to identify in Table 2 the country where the included studies have been carried out in a clearer way. Explain the acronyms used at the foot of each table (example: HUMV). Remove own elaboration at the foot of tables.

Explain the acronyms used in the text (AEP, HUMV...) in the first use in the text of the manuscript (it is not valid if they have been explained in the table). Authors should also explain the acronyms used in the tables at the foot of the table (rather than within the content of the tables).

Discussion:

The discussion should be improved and their wording should be revised so that they do not appear to be adding unconnected sentences.

To improve the discussion, this discussion should be organized according to different groups of reasons for delayed hospital discharge (use the same groups of reasons identified in the results and explain in conclusions).

Author Response

Referee 1.

Thank you very much for the comments and time spent reading this work.

Next, we respond to the comments made. All the changes introduced are indicated in the document (marked in red).

Dear authors, thank you for the opportunity to read your manuscript.

In this second version is needed to perform the manuscritp according PRISMA-ScR statement.

We have improved the manuscript according to PRIMSA guidelines following your advice.

You're right, we changed it.

Abstract: Method needs to be explained in more detail: terms used, eligibility criteria, sources of evidence, charting methods.

We have improved this section following your instructions.

Material and methods:

We have improved this section in the text.

The question guiding the research should be included.

We have already corrected.

Page 2 (line 79): you must explain the acronym PRISMA (and express it in capital letters).

You're right, we changed it.

You are right, this is a bug that we have already corrected.

In table 1 include each database in separate rows. Cinahl and Medline have used the same search strategy? (the one described in Table 1 looks like cinahl).

We have modified it in the table.

We modified it in the text.

Results:

Figure 1 is not displayed correctly (it is more appropriate to use the model proposed by PRISMA since you use this methodology in the results report).

You are right, we have modified the flow chart and it is now in accordance with PRISMA instructions.

In the flowchart, in the identification step does not show the results in each of the databases. How many duplicates were eliminated? Explain better the diagram content in the text.

We modified it in the text.

We have improved the wording in the conclusions section so that they are better understood. We have modified the sections described.

Try to locate the figures and tables just below the citation in the text.

We change it.

You're right, we changed it.

We modify it.

You're right, we changed it un the text.

Discussion:

The discussion should be improved and their wording should be revised so that they do not appear to be adding unconnected sentences.

We have improved this section following your instructions.

Author Response File: Author Response.pdf

Reviewer 2 Report (Previous Reviewer 2)

Comments and Suggestions for Authors

The authors improved the paper according to reviewers statements.

Comments on the Quality of English Language

Minor editing of English language required.

Author Response

Thank you very much for the comments and time spent reading this work.

The authors improved the paper according to reviewers statements.

Comments on the Quality of English Language

Minor editing of English language required.

The document has been reviewed by a native English speaker.

Round 2

Reviewer 1 Report (Previous Reviewer 1)

Comments and Suggestions for Authors

Dear authors, thank you for your improvements in the manuscript.

In the methods section, exclusión criteria, it is not neccesary to explain: "We excluded articles that did not meet the inclusion criteria". In this section, you must only explain: Summaries, editorials, comments, and book reviews were excluded.

Since you have specified in the flowchart to included studies retrieved using a "snowball" strategy by consulting the references of the included studies, this process should be identified at the end of the "search strategy" section marked as additional searches.

In figure 1, the arrows should be better edited so that the diagram is better represented.

In table 2 have included a new acronym (OECD) which should be explained at the foot of the table.

Author Response

Referee 1.

Dear authors, thank you for your improvements in the manuscript.

You're right, we changed it.

You're right, we included it in the search strategy.

In figure 1, the arrows should be better edited so that the diagram is better represented.

It was a formatting error, we have corrected it.

In table 2 have included a new acronym (OECD) which should be explained at the foot of the table.

Corrected in the text

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear authors,

The scoping review presented here deals with a very interesting topic in the context of Spain. The comments I am going to make are based on the recommendations for the reporting of results according to the PRISMA-ScR statements.

Title: correct.

Abstract: The content should be aligned, as far as possible, with the following points: Provide a structured summary that includes (as applicable): background, objectives, eligibility criteria, sources of evidence, charting methods, results, and conclusions that relate to the review questions and objectives. According this statement, the content of the method should be improved.

Keywords: For a correct indexing, the keywords must correspond to MesH terms. You have used two similar terms (Delayed discharges; Discharge delays) but neither is a Mesd; you have not used the descriptor "Patient Discharge". "Bed-blocking", "Timely discharge", "Unnecessary days", "Inappropriate stays" are also not MesH terms.

Introduction: Correct.

Methods: You must cite JBI methodology and explain the acronym on the first occasion it is mentioned (page 2, line 73), not on the second (page 2, line 79); reference and more information on the development of the JBI methodology can be found at this link: https://jbi-global-wiki.refined.site/space/MANUAL/4687342/Chapter+11%3A+Scoping+reviews.

It is not described whether the review protocol has been registered (e.g. in OSF).

On page 3 (line 88) should correct that the database in Medline (not PubMed). Specify all databases consulted.

As described in an above comment, the terms used do not correspond to MeSH. It should be specified if they correspond to free terms.

The information on the number of records retrieved and selected should not be included in table 1; it corresponds to results (this information is duplicated with the information included in the flowchart).

In point 2.2 it is necessary to distinguish information concerning inclusion/exclusion criteria and selection criteria (it is recommended to separate into two sub-sections).

It is not made clear whether a critical reading tool has been used in the peer review process (only consensus is mentioned in case of discrepancies, but the information provided is unclear).

Data analysis: in my opinion it is more correct to describe first data extraction and then synthesis of results.

The flow chart does not follow prisma statements: http://www.prisma-statement.org/PRISMAStatement/FlowDiagram. Identification, screening and elegibility should refer to records (not papers); and inclusion phase refers to Studies included. Not duplicate records are described in the flowchart.

Table 2 has been omitted from the manuscript. Table 3 is understood to correspond to table 2.

Discussion: Review the discussion of the use of acronyms (e.g. Appropriateness Evaluation Protocol (AEP) is noted twice (line 150 and 229).

There is a lack of discussion of results with other international contexts similar to Spain.

References: check proper use for referencing and add link or DOI to the primary source.

Author Response

ANSWER TO REVIEWERS

Thank you very much for the comments and time spent reading this work.

Please find below our responses to the reviewers’ comments. All the changes introduced are indicated in the document (marked in red).

REFEREE 1

Yes, we have changed, especially, the method has been improved.

Keywords has been rewritten and we have used MesH terms and free terms, because we consider that when searching through MeSH terms, only articles indexed in Medline are retrieved, while when using free vocabulary, we can search all PubMed records.

Introduction: Correct.

You are right, we have modified it in the text.

It is not described whether the review protocol has been registered (e.g. in OSF).

We have registered the protocol, we modify it in the text.

On page 3 (line 88) should correct that the database in Medline (not PubMed). Specify all databases consulted.

We've actually searched PubMed and not just Medline.

As described in an above comment, the terms used do not correspond to MeSH. It should be specified if they correspond to free terms.

You are right, we have used free terms and we justified it at the beginning of the discusión.

You are right, we have already removed the search results, since as indicated they should be included in the results section.

In point 2.2 it is necessary to distinguish information concerning inclusion/exclusion criteria and selection criteria (it is recommended to separate into two sub-sections).

We have modified it following your instructions.

It is not made clear whether a critical reading tool has been used in the peer review process (only consensus is mentioned in case of discrepancies, but the information provided is unclear).

We do not use critical reading tools during peer review. Two reviewers developed the search strategy, which was peer-reviewed, considering the inclusion and exclision criteria. Disagreements between reviewers about whether the articles found met the inclusion criteria were resolved were resolved through discussion or with a third reviewers.

Data analysis: in my opinion it is more correct to describe first data extraction and then synthesis of results.

We have already modified it in the table.

You are right, we have modified the flow chart.

Table 2 has been omitted from the manuscript. Table 3 is understood to correspond to table 2.

Yes, it is an error, which we have already modified.

Discussion: Review the discussion of the use of acronyms (e.g. Appropriateness Evaluation Protocol (AEP) is noted twice (line 150 and 229).

We have already modified it in the corrected version.

There is a lack of discussion of results with other international contexts similar to Spain.

We have added to the discussion a comparison part with other studies from similar contexts and the corresponding bibliographic citations in the references section.

References: check proper use for referencing and add link or DOI to the primary source.

We have improved this section, as you have indicated.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review the manuscript “Evaluation of delayed effective discharge for non-medical reasons of patients admitted to acute care hospitals in Spain: a Scoping Review” (nursrep-2692825).

Authors conducted a review to evaluate the delay in discharge for non-medical reasons in patients admitted to acute care hospitals. The topic is important, but the content needs to be significantly improved.

Introduction:

Line 42: please add: failure of health policy

The content of the studies used in the introduction must be elaborated in more detail.

Results:

Please give information of study results belonging to the Spain situation. If these results are not available, the group of countries must be expanded, e.g. EU.

Table 3:

Pellico-López, Fernández-Feito et al., (2022) [18]: What was in this study the main reason of a non-medical reason

Pellico-López, HerreroMontes, (2022) [19]: this is a medical reason for a prolong hospital stay

Pellico-López, Fernández Feito, Cantarero et al., (2021)[16]: cost are not the subject of this study

Rojas-García et al., (2018) [2]: what concret? that's too superficial.

Monteis-Catot et al., (2007)[24]: too short information.

Zambrana García et al., (2001) [22]: non content information

In the Europe health care systems average duration of stay decreased to six days, in 2000 it was about nine to eleven days. During this time, medical care also developed further.

This is also a point for limitation.

Discussion:

Line 142 and 169: It also must be distinguished between different therapy concepts such as holistic-multimodal approaches. What is meant is: Multimodal therapy concepts that include several comorbidities in the treatment during a hospital stay, please add important reference https://doi.org/10.1177/2156587214555714

Line 150: Discuss in what way and to what extend AEP taken into account chronic patients with acute exacerbation of their diseases. This is also a point for limitation.

Comments on the Quality of English Language

moderate improvements.

Author Response

ANSWER TO REVIEWERS

Thank you very much for the comments and time spent reading this work.

Please find below our responses to the reviewers’ comments. All the changes introduced are indicated in the document (marked in red).

REFEREE 2

Introduction:

Line 42: please add: failure of health policy

The content of the studies used in the introduction must be elaborated in more detail.

We believe we have improved the introduction following your guidance.

Results:

Please give information of study results belonging to the Spain situation. If these results are not available, the group of countries must be expanded, e.g. EU.

We have added to the discussion the comparison with studies from countries with similar contexts and the corresponding bibliographic citations in the references section.

In the review we wanted to focus only on Spain because we believe that adding more countries would be a confusing factor, as the reviewed bibliography indicates, we are facing a problem closely related to sociodemographic characteristics and the health system.

Table 3:

Pellico-López, Fernández-Feito et al., (2022) [18]: What was in this study the main reason of a non-medical reason.

We have modified the table to improve the information contained therein.

Pellico-López, HerreroMontes, (2022) [19]: this is a medical reason for a prolong hospital stay.

You're right, but the patients in the study were identified as clinically fit for medical discharge by the hospital’s admission department, but whose actual discharge was delayed by more than 24 h. For this reason, we thought it was a relevant study. We have improved the wording in the table.

Pellico-López, Fernández Feito, Cantarero et al., (2021)[16]: cost are not the subject of this study

The objective of this review is to evaluate the delay in effective discharge for non-medical reasons and this article provides information that we consider relevant.

Rojas-García et al., (2018) [2]: what concret? that's too superficial.

Monteis-Catot et al., (2007) [24]: too short information.

Zambrana García et al., (2001) [22]: non content information

You are right, we have modified it in the text.

Please also note that some of the studies do not provide sufficient information about the current status of the health system(s). This is also due to the age of the studies. Some are over 20 years old.In the Europe health care systems average duration of stay decreased to six days, in 2000 it was about nine to eleven days. During this time, medical care also developed further. This is also a point for limitation.

You are right, we have added this statement as a limitation of the study.

Discussion:

This article has been cited in the discussion

Line 150: Discuss in what way and to what extend AEP taken into account chronic patients with acute exacerbation of their diseases. This is also a point for limitation.

You are right, we have added this statement as a limitation of the study.

Author Response File: Author Response.pdf