Framework for a Modular Emergency Departments Registry: A Case Study of the Tasmanian Emergency Care Outcomes Registry (TECOR)

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript is well-structured, methodologically sound and clearly articulates the significance of its contribution to Emergency Department quality evaluation through the development of the TECOR framework. The case study approach using TECOR adds practical relevance.  The authors articulate the unique challenges of ED quality evaluation, such as data fragmentation and governance complexity, which justify the need for a modular CQR framework. The methodology section is thorough and includes appropriate categorization of data sources (self-extractable, manual, on-request), integration challenges, and the classification of data elements across multiple hospital systems. The framework includes relevant data points capturing patient flow from ED to admission, long-term care, or community services, as well as time to first medical encounter—key indicators for clinical performance and operational efficiency.

May I suggest some areas for improvement. The framework currently lacks integration with pre-hospital care data. Given the critical impact of pre-hospital interventions on ED outcomes, incorporating ambulance and paramedic data would significantly enhance the comprehensiveness of the framework. While readmission-related data points are available, the manuscript does not explicitly identify readmission as a key outcome metric. It would be beneficial to highlight this aspect and discuss its relevance to ED quality and continuity of care. The manuscript focuses on system-level and clinical metrics but does not address person-centered outcomes (PREMS) and staff well-being or burnout, which are integral to sustainable quality improvement in high-pressure ED environments. While demographics are mentioned, the manuscript does not explore equity in care delivery, such as differences in access, timeliness, or outcomes across socioeconomic or minority groups. The focus is predominantly retrospective. Expanding the discussion to consider real-time data monitoring, decision support tools, and emerging technologies (such as AI, predictive analytics) would modernize the framework and reflect innovation trends in emergency care. The exemption from formal ethics review for data mapping is noted. However, the authors could strengthen the manuscript by discussing how ethical considerations were managed to ensure patient data privacy and governance compliance.

As regards discussion and conclusions, while the results highlight challenges such as fragmented data and manual data entry, the conclusion does not fully address how TECOR mitigates these issues or the limitations of the framework. The conclusion asserts the efficiency of TECOR, but the results do not provide quantitative metrics or validation to directly support this claim. The conclusion suggests that TECOR's modular framework could be applied broadly to EDs, but the results are specific to Tasmanian EDs and do not include comparisons or evidence from other settings.  Some sections, particularly the discussion, could benefit from smoother transitions between ideas to improve the overall flow.

Some other suggestions include the consideration of a brief cost-effectiveness perspective or rationale for resource allocation to support implementation; training and education strategies that support clinicians in using quality data effectively; and clarity of whether post-discharge outcomes are tracked systematically (such as follow-up compliance, community care success rates).

In conclusion, this manuscript makes a valuable contribution to emergency medicine and clinical quality evaluation. With the inclusion of additional dimensions, in particular pre-hospital data, patient/person-centered metrics and explicit readmission analysis, it has the potential to become a good reference in the development of modular ED CQRs.

Comments on the Quality of English Language

Certain phrases and concepts, such as "modular framework" and "data extractability," are repeated multiple times, which could be streamlined for conciseness. Some sentences are overly long and complex, making them harder to read. For example: "The TECOR framework uses Kaji et al. ​ as a cognitive aid to ensure the quality evaluation is suitable with the opportunity to refine the methods to bring the limitations to an acceptable level."

Table Formatting: Some tables, such as Table 3, are dense and could benefit from better formatting to improve readability. The lack of visual emphasis on key data points makes it harder to quickly identify important information.

Figure 1: While the concept is clear, the figure lacks detailed labelling or annotations to explain the axes or specific points. This could make it harder for readers to interpret without referring to the text.

Table 2 does not provide additional context, such as the outcomes or impact of these projects, which would make the information more meaningful.

Consistency: The presentation style of tables and figures is not entirely consistent. For example, some tables have headers repeated multiple times, which can be distracting.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

REPORT REVIEW (hospitals-3766412)

Framework for a Modular Emergency Departments Registry: A Case Study of The Tasmanian Emergency Care Outcomes Registry (TECOR)

 

ABSCTRACT

Overall, it's OK, but I suggest the authors include the number of EDs involved and the practical impact of implementing TECOR. Furthermore, the "Three categories of data extraction were identified..." seems out of context (please moderate the text).

INTRODUCTION

- The authors did a good job contextualizing the role of EDs and the challenges of measuring quality in this environment. Please revise the sentence "We reimagined the concet of CQRs..." as it seems vague and subjective. What does "reimagining" mean in this context?

- Although the authors present the idea of a modular framework as an innovation for clinical records in emergency departments, the justification requires a clear formulation of the hypothesis and identification of a gap in the literature. For example, the text states that "considering the overlap between QI, QA, OR, and CQRs, we conceptualized a modular framework...". Why does this type of overlap represent a practical or theoretical problem that requires a new approach? Please revise this setion.

METHODS

- Please include more information on how the 29 projects were selected or if there were any exclusion criteria. Furthermore, the sentence "We searched emails, newsletters, reports..." suggests an informal collection, without standardization or replicability, and should be rewriten for greater scientific rigor.

RESULTS

- The tables do not present statistical values such as p-values or CIs, which limits quantitative analysis. However, this is entirely plausible for the type of study the authors conducted. Please revise Table 3 so that the title is not included in the table, as is the case with the others.

- Why is "Trend of emergency department presentations with a mental health diagnosis in Australia by diagnostic group, 2004–05 to 2016–17" duplicatedS?

DISCUSSION

- In my opinion, the authors addressed the practical challenges faced by emergency departments well. If possible, I recommend including key findings in the first paragraph, as would be expected. Also, include evidence to support the statement "clinicians often experience intimidation or frustration...". Present data or examples that support claims about barriers faced by clinicians.

CONCLUSIONS

- Can the authors to revise the conclusion so that it clearly addresses the hypothesis or objective of the study? Also, suggest future studies based on the limitations identified.

REFERENCES

Overall, these are quite up-to-date. Please review the reference list for formatting inconsistencies, as some references have periods after the authors' names, while others do not.

Comments for author File: Comments.pdf

Author Response

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Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors, Thank you for your interesting and well-structured manuscript. The concept of a modular framework for emergency department clinical quality registries (CQRs), as demonstrated through TECOR, is timely and addresses key challenges in data fragmentation, quality improvement (QI), and observational research (OR) integration. However, some improvement is needed it Clarify the Generalizability of TECOR: While TECOR is well presented in the context of Tasmania, it would strengthen the manuscript to briefly discuss how the framework can be adapted to other healthcare systems with differing digital infrastructure and governance models. Enhance Figure Interpretability: Consider elaborating on Figures 1 and 2 in the captions or the main text to help readers better understand how they reflect the decision-making or modular design process. Protocol Repository: The proposed TECOR Protocol Repository is a strong addition. Please clarify how this will be made accessible and whether it will include only local projects or also allow for broader collaboration. While limitations are acknowledged, a more explicit section discussing challenges during implementation (e.g., staff training, engagement, or interoperability issues) would be useful for readers looking to replicate the framework. STROBE and SQUIRE Compliance: While you mention adherence to reporting standards, it may help to include a supplementary table indicating how your work aligns with these checklists for transparency and completeness. Overall, the manuscript makes a valuable contribution to emergency medicine quality evaluation literature.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf