Exploring Delayed Discharges in an Acute Hospital Setting in a Small European Member State

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear authors, after reading the manuscript, I have doubts about the authors' consideration of the study as a case study. In my opinion, it is a study that should be labelled as ‘original research’ as it is a qualitative design. The title, methodology and results suggest that this is the right way. I therefore recommend following the COREQ guidelines in writing the manuscript.

Revise the sections of the manuscript according to journal guidelines and as indicated in the template.

The title is informative, includes the population, the context and suggests a qualitative study (exploring factors). To follow the recommendation that it should not exceed 15 words, you should try to reduce it by eliminating non-essential information from the title.

Abstract: I think the key to the mix of designs is in the following sentence: ‘This study followed a qualitative approach, and the case study methodology was used’. This is indeed a qualitative approach, but I think it confuses the case study with the selection of key participants for interviews (which is the data collection technique used by the authors). Revise this aspect in the methodology. In any case, the abstract should provide more information on the method (design and approach, population, sampling, inclusion and exclusion criteria, analysis process, including software used and ethical considerations).

Keywords: review and correct that they are MeSH compliant. I recommend including ‘Qualitative Research’ to refer to the type of study.

Introduction: Figure 1 has poor resolution; the font size should be increased. The introduction should end with a description of the objective of the research (just before Methodology).

Methodology: In the ‘study design’ section, review the design and approach (¿qualitative phenomenologic?).  

Table 1 should be described in the text before citing it.

Define inclusion and exclusion criteria more clearly in the text. Clarify how participants were contacted (were they the researchers themselves or was a gatekeeper used to access the population). Also explain whether or not the researchers knew the participants previously. Were participants who did not agree to participate in the study contacted?

Clarify whether an uninterrupted environment was ensured during the interviews and whether other persons were present during the interviews.

In the data collection section, it should be made clear from the outset that two techniques have been used for data collection (semi-structured interview and focus group). Subsequently, describe each as appropriate.

In focus groups, clarify the number of participants, the number of researchers (if one researcher is a moderator and the other an observer, the arrangement of people in the group,...).

The process of group composition should be further clarified to ensure homogeneity.

Ethical considerations: Move this section to the end of the methodology.

data analysis: clarify and specify which researchers conducted the transcriptions; were they the same researchers who conducted the interviews and focus groups? In this section we introduce a piece of information that has not been sufficiently explained or clarified before about the composition of the groups (were there separate groups for ‘doctors’, nurses,... (explain this aspect in the previous section)?

Further specify the analysis process: emergent vs. intentional coding, identification of sub-themes and themes, qualitative software, researchers who conducted the analysis. Clarify data saturation issues.

Cite tables just before placing them in the text (table 4 is cited before table 3, but is placed in the text below).

Table 2 includes results on the characteristics of the participants. As these are results, this information should be included in the findings section. In any case, the table should show more concrete information for each participant. It seems that table 2 refers to inclusion criteria rather than to concrete results of the participants. For example, participant nurse - only one nurse? with what experience each of the nurses? in which setting does the nurse or each of the nurses work? Acronyms in tables should be clarified at the foot of the table.

page 6, lines 247, identify in the text the specific number of the appendix

page 7, line 256, not to cite Rolfe (2006) in this way because it looks like APA style.

Include a section with the characteristics of the researchers: training, experience in qualitative research, are they employees of the same hospital? ) general information that can contextualise this aspect.

The Fingins and discussion sections should be separated.

Do not start the results with the objective of the research. The results should follow the following order: characteristics of the participants, descriptive results of the interviews/focus groups: coding process, sub-themes, themes; content results. Interpretative results (if applicable).

This will be followed by a discussion, citing relevant literature and ending with the limitations of the research and conclusions. Many quotations are missing from the discussion.

Conclusions should be less general and more specific in order to respond more clearly to the objective based on the findings.

Author Response

Dear authors, after reading the manuscript, I have doubts about the authors' consideration of the study as a case study. In my opinion, it is a study that should be labelled as ‘original research’ as it is a qualitative design. The title, methodology and results suggest that this is the right way. I therefore recommend following the COREQ guidelines in writing the manuscript. 

Revise the sections of the manuscript according to journal guidelines and as indicated in the template.

 

We appreciate this observation and fully agree with the reviewer’s assessment. The manuscript has been reclassified as an original research article, and all sections were revised to align with the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist. This ensures methodological transparency and completeness in reporting.

Added statement in methods: “This study was conducted and reported in accordance with the COREQ guidelines for qualitative research.”

 

The title is informative, includes the population, the context and suggests a qualitative study (exploring factors). To follow the recommendation that it should not exceed 15 words, you should try to reduce it by eliminating non-essential information from the title.

We thank the reviewer for this recommendation. The title was revised to maintain clarity and focus while complying with the journal’s 15-word limit.

Changed title to: “Exploring delayed discharges in an acute hospital setting in a small European member state.”

Abstract: I think the key to the mix of designs is in the following sentence: ‘This study followed a qualitative approach, and the case study methodology was used’. This is indeed a qualitative approach, but I think it confuses the case study with the selection of key participants for interviews (which is the data collection technique used by the authors). Revise this aspect in the methodology. In any case, the abstract should provide more information on the method (design and approach, population, sampling, inclusion and exclusion criteria, analysis process, including software used and ethical considerations).

Thanks for this suggestion. The abstract was comprehensively revised to eliminate confusing references to “case study” and to clearly present the qualitative design, study population, inclusion/exclusion criteria, sampling method, data analysis approach (Braun & Clarke), ethical approval, and qualitative software use (or absence thereof).

Revised methodology portion of abstract to state: 'Semi-structured interviews (n = 28) and focus groups (n = 2) were conducted with a diverse group of experienced health professionals. Informed consent was obtained from all participants, and all data were treated with strict confidentiality throughout the study. The sample was limited to pro-fessionals working in adult, non-specialized healthcare settings. Manual thematic analysis was per-formed by the researcher and colleagues, following Braun and Clarke’s (2006) approach.

Keywords: review and correct that they are MeSH compliant. I recommend including ‘Qualitative Research’ to refer to the type of study.

We thank the reviewer for this technical recommendation. All keywords were reviewed and replaced to ensure compliance with MeSH terminology.

Added “Qualitative Research”

Introduction: Figure 1 has poor resolution; the font size should be increased. The introduction should end with a description of the objective of the research (just before Methodology).

We appreciate this formatting observation. Figure 1 was replaced with a high-resolution version with larger, legible font to ensure clarity for readers.

Replaced figure with enhanced image. Font size increased to journal-standard readability.

This is an important structural suggestion. The final paragraph of the Introduction now ends with a clearly stated objective, aligning the narrative with the study’s focus.

Added: “This study aims to explore the perspectives of healthcare professionals regarding systemic and procedural factors contributing to delayed discharges from a Maltese acute hospital.”

Methodology: In the ‘study design’ section, review the design and approach (¿qualitative phenomenologic?).  

Thank you for this comment. The Methods section now specifies that the study used a qualitative descriptive approach, rooted in a constructivist paradigm, consistent with health services research practices.

Added: “A qualitative descriptive design was adopted, using a constructivist lens to explore participants’ lived experiences and operational insights.”

 

Table 1 should be described in the text before citing it.

We agree with the reviewer and ensured all tables are introduced in the text before their appearance. Table 1 is now referenced and explained immediately before it appears.

Adjusted paragraph to read: “Table 1 (below) shows the stakeholders selected for this study based on the model developed from the scoping review”

Define inclusion and exclusion criteria more clearly in the text. Clarify how participants were contacted (were they the researchers themselves or was a gatekeeper used to access the population). Also explain whether or not the researchers knew the participants previously. Were participants who did not agree to participate in the study contacted?

These critical elements have been addressed comprehensively. We now detail the inclusion criteria, exclusion, recruitment, and explicitly state whether any participants were known to the researchers or declined participation.

“Nurses were reached through their ward managers, who distributed the invitations via email along with information letters, consent forms, and inclusion/exclusion criteria. Interested nurses contacted the researcher directly by email. Doctors were contacted via email using the intra-hospital medical specialty list to select participants from various specialties, ensuring diversity. Due to their smaller numbers, other health professionals were approached personally within their departments. The researcher did not personally know any of the nurse or doctor participants; however, it was more challenging to maintain anonymity with professionals from smaller groups, such as geriatricians and Discharge Facilitation/Discharge Liaison Nurse staff..”

Clarify whether an uninterrupted environment was ensured during the interviews and whether other persons were present during the interviews.

We thank the reviewer for highlighting this oversight. We now specify that interviews and focus groups were conducted in private staff rooms to ensure confidentiality and uninterrupted discussion.

Added: “For both interviews and focus groups, a quiet room was selected to minimize the chance of interruptions. During individual interviews, only the researcher was present. However, a second colleague assisted during the focus groups to help capture nonverbal cues that might have been missed in the audio recordings.”

In the data collection section, it should be made clear from the outset that two techniques have been used for data collection (semi-structured interview and focus group). Subsequently, describe each as appropriate.

We appreciate the need for clarity here. The Methods section now explicitly states that both semi-structured interviews and focus groups were used as primary data collection methods, and their sequencing and rationale are clearly explained.

Added: “Two data collection techniques were employed: semi-structured interviews and focus groups. Interviews provided individual perspectives, while focus groups enabled interactive exploration of shared challenges.”

In focus groups, clarify the number of participants, the number of researchers (if one researcher is a moderator and the other an observer, the arrangement of people in the group,...).

We now provide detailed information on the number of focus groups, participant composition, moderator/observer roles, and procedures used to ensure consistency.

Added: “Focus groups were conducted solely when investigating doctors’ views and bed management personnels’ views.  The doctor’s focus group consisted of 5 participants while the bed management’s focus group was made up of 4 participants”

The process of group composition should be further clarified to ensure homogeneity.

Addressed alongside the above. The composition was role-based to encourage free dialogue among peers.

Added sentence: “The two focus groups, albeit distinct, were purposefully homogenous in composition in that the first group included doctors, while the second group included members of staff within the bed management unit. This enabled participants to discuss the subject through a shared working environment standpoint.”

Ethical considerations: Move this section to the end of the methodology.

Implemented. Ethical approval details are now presented at the conclusion of the Methodology section for logical flow.

Ethics now under sub-section 3.4.

data analysis: clarify and specify which researchers conducted the transcriptions; were they the same researchers who conducted the interviews and focus groups? In this section we introduce a piece of information that has not been sufficiently explained or clarified before about the composition of the groups (were there separate groups for ‘doctors’, nurses,... (explain this aspect in the previous section)?

We clarify who transcribed the data (same as interviewers), how coding was conducted, and how thematic saturation was reached. Group segmentation by profession is also stated.

Added: “Interviews were transcribed verbatim by the interviewer. Data from different focus groups were analysed separately to preserve contextual integrity. Saturation was reached when no new themes emerged from subsequent data.”

Further specify the analysis process: emergent vs. intentional coding, identification of sub-themes and themes, qualitative software, researchers who conducted the analysis. Clarify data saturation issues.

Clarified that coding followed an inductive (emergent) approach based on Braun & Clarke. Manual coding was conducted, and two researchers verified themes.

Added: “Code identification was performed manually without the use of software. This approach was chosen to ensure the reliability of results through the application of human judgment. Although this method can be criticized for potential researcher bias, the coding of interview and focus group transcripts was conducted independently by two researchers. This helped to reduce bias. The two sets of codes were then compared and contrasted, resulting in a common set of codes. This process was particularly valuable in distinguishing between emergent and intentional codes, where some discrepancies between the researchers’ findings were expected. Codes that were not common to both researchers were either re-evaluated or excluded. The emergence of seven themes from the 41 derived codes occurred through collaborative discussions among all researchers, following a careful definition of each code (see Appendix). It is important to note that determining data saturation was challenging due to the heterogeneity of the sample, which included a wide variety of health professionals. However, the researchers considered the high frequency of recurring issues across different respondents as a strong indication that data saturation had been reached.”

Cite tables just before placing them in the text (table 4 is cited before table 3, but is placed in the text below).

Adjusted. Tables are now cited in correct numerical order.

Corrected in Results narrative.

Table 2 includes results on the characteristics of the participants. As these are results, this information should be included in the findings section. In any case, the table should show more concrete information for each participant. It seems that table 2 refers to inclusion criteria rather than to concrete results of the participants. For example, participant nurse - only one nurse? with what experience each of the nurses? in which setting does the nurse or each of the nurses work? Acronyms in tables should be clarified at the foot of the table.

Revised. Table 2 has been moved to the Findings section and expanded

Table moved to the relevant section.

page 6, lines 247, identify in the text the specific number of the appendix

Appendix reference now made explicit.

Amended to read: “…(see Appendix 1).”

page 7, line 256, not to cite Rolfe (2006) in this way because it looks like APA style.

Corrected. APA-style formatting removed; reference now matches journal style.

Corrected.

Include a section with the characteristics of the researchers: training, experience in qualitative research, are they employees of the same hospital? ) general information that can contextualise this aspect.

Addressed. A dedicated paragraph describes researcher training in qualitative research, institutional affiliation, and role within the study.

Added paragraph: “All researchers involved in the data analysis have a background in health systems leadership and training (as well as experience) in qualitative research. None of the research team were line managers of participants.”

The Findings and discussion sections should be separated.

Thank you for your suggestion.  After careful deliberation we have opted to leave the findings, and the discussion intertwined as it offers a more insightful picture of the study and how researchers chose to interpret findings. 

Our layout has the potential to allow the reader to follow a more flowing read, as issues are addressed and discussed as they are stated.  

Do not start the results with the objective of the research. The results should follow the following order: characteristics of the participants, descriptive results of the interviews/focus groups: coding process, sub-themes, themes; content results. Interpretative results (if applicable).

Revised according to standard qualitative reporting structure.

Results now follow this order: participant demographics, coding process, subthemes, key themes, then findings.

This will be followed by a discussion, citing relevant literature and ending with the limitations of the research and conclusions. Many quotations are missing from the discussion.

Discussion was revised to incorporate relevant international literature and clarify implications for practice. A limitations section was added to reflect methodological constraints.

Added references to European delayed discharge studies; discussed transferability. Limitations included in final paragraph of Discussion.

Conclusions should be less general and more specific in order to respond more clearly to the objective based on the findings.

We revised the conclusion to directly reflect findings and implications.

Rewritten: “Findings suggest a need for structured discharge planning, improved interdisciplinary communication, and increased community care resources. These measures are essential to reduce discharge delays in Malta’s centralized acute care setting.”

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript presents a qualitative study investigating the causes of delayed discharges in Malta’s hospital. Using a combination of semi-structured interviews and focus groups, the authors extract seven core themes and provide recommendations. The research offers practical value for small European healthcare systems. However, the manuscript requires revision to improve its novelty positioning, methodological transparency, citation consistency, and clarity of expression.

The issue of delayed discharges is globally relevant, but the manuscript’s novelty is weakened by limited comparison with similar studies from other small European states. The authors claim this is the first study in Malta; however, the value-added over existing literature is not clearly articulated. Suggestions: to strengthen the discussion of Malta’s uniqueness, to emphasize how findings contribute new understanding or challenge assumptions in existing research.

Objectives are implied but not clearly stated or systematically connected to findings. Suggestions: to add a numbered objectives section, then link findings to research questions in the discussion.

Good use of qualitative case study methods. However, the description is unnecessarily long and includes redundant or textbook-like material that could be shortened.

Please mention any use of qualitative data analysis software (such as NVivo). If all steps were done manually, please justify how they ensured coding without software (e.g., codebook consistency, audit trail), whether any inter-coder verification was used (none was mentioned).

Thematic structure is rich but occasionally repetitive and overlapping. Suggestions: to trim long quotes, use diagrams to link themes, add more critical synthesis across findings.

Practical suggestions are helpful but lack prioritization and feasibility discussion. Suggestions: to indicate short vs long-term fixes, and to assess generalizability to other healthcare systems.

The manuscript is lengthy and wordy in parts. Consider rephrase expressions like “precious pertinent data” (Line 194) or “food for thought.” (line 489)…

Add space and format citation properly (E.g. Line 101, 115 etc).

Line 577: “applied to applied to”

Author Response

This manuscript presents a qualitative study investigating the causes of delayed discharges in Malta’s hospital. Using a combination of semi-structured interviews and focus groups, the authors extract seven core themes and provide recommendations. The research offers practical value for small European healthcare systems. However, the manuscript requires revision to improve its novelty positioning, methodological transparency, citation consistency, and clarity of expression. The issue of delayed discharges is globally relevant, but the manuscript’s novelty is weakened by limited comparison with similar studies from other small European states. The authors claim this is the first study in Malta; however, the value-added over existing literature is not clearly articulated. Suggestions: to strengthen the discussion of Malta’s uniqueness, to emphasize how findings contribute new understanding or challenge assumptions in existing research.

We appreciate the reviewer’s emphasis on positioning our study within a broader context. We revised both the introduction and conclusions to highlight Malta’s unique healthcare system (centralized service, limited LTC availability), and compared our findings with similar European studies, noting both convergence and divergence. We now more explicitly articulate how this study contributes to the international discourse on delayed discharges.

Added comparative analysis with small EU nations like Cyprus, Luxembourg, and Estonia; positioned Malta’s system as a case of structural centralization with implications for discharge pathways.   In the introduction: “Furthermore, comparative insights from other small EU member states such as Cyprus, Luxembourg, and Estonia further highlight the structural centralization characteristic of Malta’s health system. While all these nations face capacity limitations due to scale, Malta distinguishes itself through its pronounced dependency on a single acute public hospital for nearly all secondary and tertiary care. This centralization contributes to greater system-ic vulnerability, particularly regarding discharge pathways, as there is limited flexibility for patient spillover or redistribution. In contrast, although small, countries like Luxembourg and Estonia have adopted more distributed or mixed-care models that incorporate regional facilities and private partnerships, providing additional buffers during peak dis-charge pressures. As a result, delayed discharges in Malta are not just the outcome of procedural inefficiencies but are deeply embedded in the structural design of its centralized health system.”   In the discussion: “For further research, the findings of this study may also be contextualized within the broader European landscape, particularly when compared to other small EU member states such as Cyprus, Luxembourg, and Estonia. While all face similar challenges inherent to scale—such as limited healthcare infrastructure and constrained human re-sources—Malta's uniquely centralized system, where the bulk of acute and specialized care is delivered through a single public hospital, creates a distinct bottleneck. Unlike Estonia or Luxembourg, which have implemented more regionally distributed or mixed public-private healthcare networks, Malta’s structural centralization leaves little room for patient diversion or flexible discharge planning. This rigidity intensifies the impact of procedural inefficiencies and social case delays, particularly in the absence of intermediate care settings or step-down facilities. These comparative insights underscore the need to explore system-level reforms that enhance discharge agility—either through decentralization of services or stronger integration with community-based care pathways.”

Objectives are implied but not clearly stated or systematically connected to findings. Suggestions: to add a numbered objectives section, then link findings to research questions in the discussion.

This is a valuable observation. We revised the Introduction to include a clearly labeled, numbered list of research objectives, and ensured they are referenced in the Discussion when linking themes to the study aims.

Inserted in Introduction: “This study aimed to: (1) identify contributing factors to delayed discharges; (2) understand health professionals’ perspectives; and (3) propose context-specific recommendations.” Cited objectives throughout Discussion.

Good use of qualitative case study methods. However, the description is unnecessarily long and includes redundant or textbook-like material that could be shortened.

We agree and have streamlined the Methods section by synthesizing the paragraph.

Modified text: “A case study approach was selected to gain in-depth, contextualized insights into health professionals’ experiences—an approach particularly suited for exploring complex, perception-based phenomena. This study followed Merriam’s qualitative tradition, which emphasizes the use of prior literature to develop a guiding theoretical framework. Unlike Yin’s mixed-method triangulation model or Stake’s emergent design, Merriam’s approach supports a more structured, literature-informed qualitative inquiry.”

Please mention any use of qualitative data analysis software (such as NVivo). If all steps were done manually, please justify how they ensured coding without software (e.g., codebook consistency, audit trail), whether any inter-coder verification was used (none was mentioned).

Thank you for raising this point. We confirm that all analysis steps were conducted manually. The coding process is now explained in greater depth, including inter-coder verification and codebook development.

Added: “Code identification was performed manually without the use of software. This approach was chosen to ensure the reliability of results through the application of human judgment. Although this method can be criticized for potential researcher bias, the coding of interview and focus group transcripts was conducted independently by two researchers. This helped to reduce bias. The two sets of codes were then compared and contrasted, resulting in a common set of codes. This process was particularly valuable in distinguishing between emergent and intentional codes, where some discrepancies between the researchers’ findings were expected. Codes that were not common to both researchers were either re-evaluated or excluded. The emergence of seven themes from the 41 derived codes occurred through collaborative discussions among all researchers, following a careful definition of each code (see Appendix). It is important to note that determining data saturation was challenging due to the heterogeneity of the sample, which included a wide variety of health professionals. However, the researchers considered the high frequency of recurring issues across different respondents as a strong indication that data saturation had been reached.”

Thematic structure is rich but occasionally repetitive and overlapping. Suggestions: to trim long quotes, use diagrams to link themes, add more critical synthesis across findings.

We appreciate this observation. The thematic structure was revised for coherence. We removed overlapping subthemes and combined closely related ones.

Section re-arranged.

Practical suggestions are helpful but lack prioritization and feasibility discussion. Suggestions: to indicate short vs long-term fixes, and to assess generalizability to other healthcare systems.

The Conclusion section now differentiates between short-term operational adjustments and long-term policy shifts. We also discussed the potential for generalizing our recommendations to similar small or centralized healthcare systems.

Added subsection to Conclusion: “At the operational level, clearer job descriptions for health professionals are needed to streamline the consultation process and reduce inefficiencies. Implementing more robust, IT-enabled consultation systems could further support timely decision-making. At the tactical and strategic levels, the findings point to a need for expanded long-term care capacity, improved A&E admission protocols, and more structured discharge planning guidelines. Transitioning elements of care from acute hospitals to community settings—alongside appropriate staff reallocation—may help alleviate discharge delays and mitigate bed-blocking”

The manuscript is lengthy and wordy in parts. Consider rephrase expressions like “precious pertinent data” (Line 194) or “food for thought.” (line 489)…

We agree with this stylistic feedback. All expressions flagged by the reviewer were revised or removed to ensure a concise and professional tone throughout the manuscript.

Replaced with: “valuable insights” and “thought-provoking findings,” among others. Removed repetition and simplified sentence structures.

Line 577: “applied to applied to”

Thank you for catching this. The typo was corrected.

Revised to: “applied to…”

Add space and format citation properly (E.g. Line 101, 115 etc).

This issue has been comprehensively addressed. All in-text citations were formatted in line with the journal’s guidelines, and spacing issues were corrected during proofreading.

Corrected in-text citation style, removed APA-style parentheticals where inappropriate, added spaces where missing.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Dear authors, thank you very much for the changes you have made to the manuscript. In my opinion, the methodology is better explained in this new version. To improve the structure of the manuscript, I recommend making a further adjustment to the structure and separating the findings and discussion into different sections. In addition, sections 5 Factors contributing to delayed discharges; 6 Faulty system which is open to abuse and inefficiency; 7 Procedural delays directly...; 8 Long-term care/social...; 9 The impact...; 10 Interventions...; 11 The impact...; 12 Interprofessional...; 13 Limitations should not be on the same level as the sections Finding and discussion (all these sections correspond to categories of results within the results section).

The conclusions are very extensive. They should be limited to responding to the objectives and, in any case, add some information about implications for clinical practice. The rest of the information included corresponds to the discussion (please note that the conclusions should not include data from other studies or references).

Author Response

Dear authors, thank you very much for the changes you have made to the manuscript. In my opinion, the methodology is better explained in this new version.

Thank you for this feedback

To improve the structure of the manuscript, I recommend making a further adjustment to the structure and separating the findings and discussion into different sections. In addition, sections 5 Factors contributing to delayed discharges; 6 Faulty system which is open to abuse and inefficiency; 7 Procedural delays directly...; 8 Long-term care/social...; 9 The impact...; 10 Interventions...; 11 The impact...; 12 Interprofessional...; 13 Limitations should not be on the same level as the sections Finding and discussion (all these sections correspond to categories of results within the results section).

Thank you for your comment.  The Findings and the Discussion section were separated as advised.  The Limitations section was also assigned its own section (apart from the other sections).  In addition, the above-mentioned points were placed under the 'Discussion' heading as per your (rightly placed) advise.  

The conclusions are very extensive. They should be limited to responding to the objectives and, in any case, add some information about implications for clinical practice. The rest of the information included corresponds to the discussion (please note that the conclusions should not include data from other studies or references).

Thank you for your comment.  The conclusion section was meticulously inspected and significantly amended, with extra information, not pertinent to the conclusion section, removed.   The following text was also added to the conclusion section to address study implications for clinical practice, "This study draws particular attention upon the long -term care problem that was very much present in study outcomes, especially in medicine wards.  The flagging process was particularly marked as much a cause of delay as the actual waiting time for a long-term care bed.  This implication for practice is in line with another implication revolving around the need for community-based care and the investment of additional human resources in the area. The study also signalled the need for admission protocols at the A+E department, together with earlier and more effective discharge planning procedures."  

Reviewer 2 Report

Comments and Suggestions for Authors

The authors responded adequately all of my comments, I think the manuscript is improved now. I have no further comments. 

Author Response

The authors responded adequately all of my comments, I think the manuscript is improved now. I have no further comments. 

Thank you for this feedback.