The Contribution of the Triage Nurse in the Optimisation of Door-to-Computed-Tomography Time in Stroke
Round 1
Reviewer 1 Report
Comments and Suggestions for Authors1. line 55: for ischemic stroke?
2. line 100: do you mean time from symptom onset to treatment/imaging?
3. line 135: can you differentiate between ischemic from hemorrhagic cases?
4. line 161: clarify how previous mRS was assessed
5. line 163/265: can more context be provided re: who the CODU, definition of Health Centre, and Outside.
6. Table 4: can this table be revised for easier reading? Starting with min max is rather confusing. Layout should improve ability to compare mean times by year and type.
7. 3.2: was there a sig. difference between triage vs post-triage activation specifically?
8. lines 218-226: would be preferable to simplify these descriptions to stating that no sig. effects were found involving these factors.
9. lines 242-243: was this age diff sig.? If not, suggest refraining from interpreting difference.
Author Response
Dear Reviewer,
We would like to express our great gratitude to the reviewer for her/his carefully reading and for her/his precious comments on it. In this letter, we provide a point-by-point reply to all issues raised by the Reviewer. We hope that we have been able to address all issues in an adequate way.
The changes in the revised manuscript are highlighted in grey.
Reviewer 1:
- line 55: for ischemic stroke?
- line 100: do you mean time from symptom onset to treatment/imaging?
- line 135: can you differentiate between ischemic from hemorrhagic cases?
- line 161: clarify how previous mRS was assessed
- line 163/265: can more context be provided re: who the CODU, definition of Health Centre, and Outside.
- Table 4: can this table be revised for easier reading? Starting with min max is rather confusing. Layout should improve ability to compare mean times by year and type.
- 3.2: was there a sig. difference between triage vs post-triage activation specifically?
- lines 218-226: would be preferable to simplify these descriptions to stating that no sig. effects were found involving these factors.
- lines 242-243: was this age diff sig.? If not, suggest refraining from interpreting difference.
Authors response:
- When discussing door-to-needle time and thrombectomy in the context of stroke, we are specifically referring to ischemic stroke in its acute phase. There's no need to specify ischemic stroke because these terms are only applicable to this type of stroke and are easily understood in the context.
- No, all other stratification was done based on the evaluation of the patient at the triage.
- We did not collect that data because our focus in the study was to demonstrate the impact of activating a stroke protocol at triage based on the presence of specific signs or symptoms from the Cincinnati Scale and tracking the progression of symptoms for up to 12 hours. Our aim, as triage nurses, is to enhance the door-to-CT time and ultimately improve patient outcomes.
- The previous mRS is a scale used to assess the patient's pre-stroke level of function during the initial evaluation by doctors and nurses. Typically, this information is obtained from the patient's family. We included it as a variable in the study to examine whether the activation of the stroke protocol was influenced by the patient's prior level of disability
- In terms of patient origin, "Outside" refers to patients who arrived at the hospital on their own, “Centre of Portuguese Urgent Patients Orientation (CODU)" refers to patients who called the emergency number and were transported to the hospital by ambulance, “Health Centre" refers to patients who initially sought care at a primary care facility and were then sent to the hospital. Most patients, 184 (81.4%), were referred by the CODU. This distribution was similar across both years (see Table 2).
- The table has been thoroughly reviewed to ensure easier comprehension and reading.
- We have changed the text: A Kruskal-Wallis test determined that the timing of VVAVC activation significantly impacted door-to-CT time. The results indicated a significant difference between triage, post-triage activation and non-activation. Activation during triage resulted in an average door-to-CT time of 35 ± 18 minutes, while post-triage activation had an average door-to-CT time of 38 ± 26 minutes. These times were significantly lower compared to cases where the protocol was not activated, which had an average door-to-CT time of 1h04 ± 45 minutes (*p=0.000).
- We changed the text: Regarding the influence of age on the activation of VVAVC, we observed that the 83-89 age group had a higher number of VVAVC activations at triage, while the under 72 age group had more post-triage activations. Non-activated cases were more prevalent in the 73-82 age group. In terms of gender, VVAVC activation at triage was higher in men, while post-triage activation was higher in women. Additionally, non-activation of the VVAVC was more common in men. Most cases had no previous symptoms (mRS=0), regardless of VVAVC activation. However, when the previous mRS score was high, there was a tendency for lower activations at triage and post-triage and an increase in non-activations. In conclusion, the analysis revealed no significant effects of age, sex, or previous mRS score on the activation of the VVAVC protocol (Table 6).
- We have changed the text: Regarding the age variable, the analysis showed that the age difference between the study years was not statistically significant (X2=2.774; p=0.428). Therefore, no significant age differences were found between the participants in the two years.
We are deeply grateful for the time and effort you have invested in reviewing our work, and we certainly remain open to any further suggestions for the continued improvement of this commentary paper.
Respectfully,
The Authors
Reviewer 2 Report
Comments and Suggestions for AuthorsI liked reading your work. Healthcare providers have recognized the significance of CT scans in the treatment of potential stroke patients for some time now. Your manuscript effectively describes the problem, provides appropriate tools for your study, and considers a cost-effective intervention to improve outcomes, with additional training for the triage nurse, who plays a valuable role in the stroke team. I found the statistics you shared to be impactful in conveying the crucial role of time to CT scans in determining outcomes.
Under the conclusion subheading, line 380, the last sentence is a powerful statement that I did not recall reading anything that clearly discussed this in the paper.
Comments on the Quality of English Language
It might read better if you consider line 378, changing "in-hosptial circuit," to "in-hospital workflow." In English, circuit usually refers to something electrical.
Author Response
Dear Reviewer,
We would like to express our great gratitude to the reviewer for her/his carefully reading and for her/his precious comments on it. In this letter, we provide a point-by-point reply to all issues raised by the Reviewer. We hope that we have been able to address all issues in an adequate way.
The changes in the revised manuscript are highlighted in grey.
Reviewer 2:
I liked reading your work. Healthcare providers have recognized the significance of CT scans in the treatment of potential stroke patients for some time now. Your manuscript effectively describes the problem, provides appropriate tools for your study, and considers a cost-effective intervention to improve outcomes, with additional training for the triage nurse, who plays a valuable role in the stroke team. I found the statistics you shared to be impactful in conveying the crucial role of time to CT scans in determining outcomes.
Under the conclusion subheading, line 380, the last sentence is a powerful statement that I did not recall reading anything that clearly discussed this in the paper.
It might read better if you consider line 378, changing "in-hosptial circuit," to "in-hospital workflow." In English, circuit usually refers to something electrical.
Authors response:
According to the findings of the international studies discussed, implementing a stroke protocol and providing training to the multidisciplinary team that handles stroke victims leads to improvements in stroke metrics and patient outcomes. Therefore, we can conclude that one way to improve results at the institution where the study was conducted is to follow a similar approach and then reassess the results.
We are deeply grateful for the time and effort you have invested in reviewing our work, and we certainly remain open to any further suggestions for the continued improvement of this commentary paper.
Respectfully,
The Authors
Reviewer 3 Report
Comments and Suggestions for AuthorsDear all,
First, thank you very much for giving me the opportunity to revise this manuscript. In general, the manuscript reports descriptive data from a single institution and the results are no distinct insights of relevance to international audience.
The following some concerns and suggestion to improve the article.
- Introduction: More details are needed to understand the need to conduct this study.
- Objective: the main objective indicated is not clear.
- Methods: This section needs to be improved. A thorough revision is necessary. In particular: i) the study design is not clear (is it a retrospective or cross-sectional study?); ii) the variables analysed need to be better specified; iii) more information on the data sources is needed.
- Results: This section is clear, but some information is not innovative (e.g. Question 1: Does the timing of VVAVC activation affect door-to-CT time?) Also check for consistency of terminology (e.g. sex/gender).
- Discussion: In this section it is important to summarise the main results. I suggest not to repeat the data presented in the results section, but only the important results. The limitations of the study need to be revised (“The study had some limitations due to the absence of recent research on the subject in Portugal and the lack of current statistical data on the prevalence and incidence of stroke in the country”, why is this a limitation?). It is also necessary to discuss the implications of these results for an international audience.
Comments on the Quality of English LanguageMinor editing of English language required
Author Response
Dear Reviewer,
We would like to express our great gratitude to the reviewer for her/his carefully reading and for her/his precious comments on it. In this letter, we provide a point-by-point reply to all issues raised by the Reviewer. We hope that we have been able to address all issues in an adequate way.
The changes in the revised manuscript are highlighted in grey.
Reviewer 3:
First, thank you very much for giving me the opportunity to revise this manuscript. In general, the manuscript reports descriptive data from a single institution and the results are no distinct insights of relevance to international audience.
The following some concerns and suggestion to improve the article.
- Introduction: More details are needed to understand the need to conduct this study.
- Objective: the main objective indicated is not clear.
- Methods: This section needs to be improved. A thorough revision is necessary. In particular: i) the study design is not clear (is it a retrospective or cross-sectional study?); ii) the variables analysed need to be better specified; iii) more information on the data sources is needed.
- Results: This section is clear, but some information is not innovative (e.g. Question 1: Does the timing of VVAVC activation affect door-to-CT time?) Also check for consistency of terminology (e.g. sex/gender).
- Discussion: In this section it is important to summarise the main results. I suggest not to repeat the data presented in the results section, but only the important results. The limitations of the study need to be revised (“The study had some limitations due to the absence of recent research on the subject in Portugal and the lack of current statistical data on the prevalence and incidence of stroke in the country”, why is this a limitation?). It is also necessary to discuss the implications of these results for an international audience.
Authors response:
- Introduction: More details are needed to understand the need to conduct this study.
Original Text:
Over the past two decades stroke incidence has decreased in Europe. In addition, the likelihood of victims' recovery has significantly improved. It can even be stated that Europe is a global pioneer in developing and enhancing the quality of care for the prevention and treatment of stroke [1,2].
Revised Text:
Over the past two decades, stroke incidence has decreased in Europe, and the likelihood of recovery for victims has significantly improved, making Europe a global pioneer in developing and enhancing stroke care. Despite this progress, studies predict an increase in stroke incidence and prevalence due to rising life expectancy in the coming decades [1-5]. Stroke remains the second leading cause of death worldwide, with approximately 12.2 million new cases annually. Furthermore, one in four people over the age of 25 is expected to suffer a stroke at some point in their lives [3]. This alarming statistic underscores the imperative for continued research and development in stroke management and preventive measures. In Portugal, stroke is the leading cause of death among circulatory system diseases, with around 10,000 deaths in 2021 [6]. Prompt diagnosis and treatment are critical as every minute of large cerebral blood vessel occlusion results in the loss of an estimated 1.9 million neurons, equivalent to 3.6 years of natural aging each hour [7]. The 'golden hour' following a stroke is crucial for successful outcomes, highlighting the need for efficient treatment protocols. The Stoke Alliance for Europe (SAFE) aims to provide equal access to stroke prevention, diagnosis, treatment, rehabilitation, and long-term support throughout Europe. By 2030, SAFE's goals include that at least 90% of stroke victims receive care in stroke units during the acute phase, with door-to-needle times less than 120 minutes and symptom onset to thrombectomy times less than 200 minutes [8].
- Objective: The main objective indicated is not clear.
Original Text:
The research question defined was "What influence does the activation of VVAVC by the triage nurse have on the door-to-CT time?" and the main objectives were: to identify the influence of the moment of activation of the VVAVC on the door-to-CT time; and to determine whether factors such as previous mRS (Modified Rankin Scale) age and sex influence the non-activation of the VVAVC.
Revised Text:
The stroke care pathway, from early detection to rehabilitation, underscores the need for a comprehensive approach to address this complex health issue. VVAVC activation aims to promote the health and well-being of suspected stroke victims using a person-centered approach. It emphasises the provision of high-quality nursing care based on scientific evidence and research in close collaboration within the healthcare team. The triage nurse plays a crucial role as the first point of contact for suspected stroke victims arriving at the ER. Therefore, the main aim of this study was to determine how the moment of VVAVC (Greenway for Stroke) activation by the triage nurse affects the door-to-CT time. Furthermore, the study sought to explore whether factors such as the Modified Rankin Scale (mRS) score, age, and sex influence the decision to activate the VVAVC.
- Methods: Thorough revision needed.
3.1 Study Design
The stroke care pathway, from early detection to rehabilitation, underscores the need for a comprehensive approach to address this complex health issue. VVAVC activation aims to promote the health and well-being of suspected stroke victims using a person-centered approach. It emphasizes the provision of high-quality nursing care based on scientific evidence and research in close collaboration within the healthcare team. The triage nurse plays a crucial role as the first point of contact for suspected stroke victims arriving at the ER. Therefore, the main aim of this study was to determine how the timing of VVAVC (Greenway for Stroke) activation by the triage nurse affects the door-to-CT time. Furthermore, the study sought to explore whether factors such as the Modified Rankin Scale (mRS) score, age, and sex influence the decision not to activate the VVAVC.
Original Text:
The study occurred in a Medical-Surgical Emergency Service of a Local Health Unit (ULS) in the Centre region of Portugal Group B. It was a descriptive cross-sectional retrospective study covering 1 January 2021 to 31 December 2022.
Revised Text:
This study was a descriptive, cross-sectional, retrospective study conducted in the Medical-Surgical Emergency Service of a Local Health Unit (ULS) in the Centre region of Portugal, Group B, covering the period from 1 January 2021 to 31 December 2022.
3.2 Variables
Original Text:
The population selected was all people over 18 who at the time of discharge from the ER had a diagnosis between codes I60 and I69 (Cerebrovascular diseases) according to the ICD-10 (International Classification of Diseases 10th Revision). The age variable was grouped into age classes by quartiles. Further stratification was done based on clinical severity at triage to provide a nuanced understanding of the age-related outcomes.
Revised Text:
The study population included individuals over 18 who, at the time of discharge from the ER, had a diagnosis between codes I60 and I69 (Cerebrovascular diseases) according to the ICD-10 (International Classification of Diseases 10th Revision).
To categorise the study, we identified independent and dependent variables. The independent variable was the door-to-CT time, while the dependent variables fell into three groups: sociodemographic factors (e.g. age and sex), clinical factors before admission (including previous mRS and origin), and clinical factors after admission (such as shift and the time of VVAVC activation). We grouped the age variable into quartiles and stratified the remaining variables based on clinical severity at triage.
3.3 Data Sources
Original Text:
The institution provided the necessary data for the study in an EXCEL® file format (Microsoft Corporation Redmond WA) with authorisation from its Ethics Committee. Throughout the process, compliance with the General Data Protection Regulation was ensured, and utmost care was taken to maintain the anonymity of the institution and confidentiality of all personal data collected.
Revised Text:
The data for this study were provided by the institution in an EXCEL® file format (Microsoft Corporation, Redmond, WA), with authorisation from its Ethics Committee. Compliance with the General Data Protection Regulation was ensured, and utmost care was taken to maintain the anonymity of the institution and the confidentiality of all personal data collected.
- Results: Clarify non-innovative information.
Original Text:
A Kruskal-Wallis test was conducted to determine the impact of the timing of VVAVC activation (during triage post-triage or not activated) on door-to-CT time. The results showed that VVAVC activations during triage had the lowest average rank (35±18 minutes) followed by post-triage activations (38±26 minutes). In contrast cases where VVAVC was not activated had the highest average rank (1h04±45 minutes). These differences were statistically significant (***p=0.000) as shown in Table 5.
Revised Text:
A Kruskal-Wallis test determined that the timing of VVAVC activation significantly impacted door-to-CT time. The results indicated a significant difference between triage, post-triage activation and non-ativation. Activation during triage resulted in an average door-to-CT time of 35 ± 18 minutes, while post-triage activation had an average door-to-CT time of 38 ± 26 minutes. These times were significantly lower compared to cases where the protocol was not activated, which had an average door-to-CT time of 1h04 ± 45 minutes (*p=0.000) (Table 5).
- Discussion: Summarize main results and revise limitations.
Original Text:
The study had some limitations due to the absence of recent research on the subject in Portugal and the lack of current statistical data on the prevalence and incidence of stroke in the country.
Revised Text:
The study had several limitations. First, there is a lack of recent research on stroke in Portugal, and current statistical data on the prevalence and incidence of stroke are insufficient. Additionally, the absence of data on pre-hospital VVAVC activations made it impossible to determine the impact of pre-hospital activation on door-to-CT time. This underscores the need for a centralized stroke database in Portugal that captures the entire continuum of stroke care from symptom onset to long-term follow-up.
Implications for International Audience
The findings of this study have significant implications for international stroke care practices. The results highlight the critical need for timely activation of stroke protocols and suggest that efficient triage and immediate activation of VVAVC can substantially reduce door-to-CT time, potentially improving outcomes for stroke patients. Further research should explore the barriers to protocol activation and develop strategies to overcome them, ensuring that stroke victims receive prompt and effective care worldwide.
We are deeply grateful for the time and effort you have invested in reviewing our work, and we certainly remain open to any further suggestions for the continued improvement of this commentary paper.
Respectfully,
The Authors
Round 2
Reviewer 3 Report
Comments and Suggestions for AuthorsDear Editor,
Thank you for giving me the opportunity to revise this manuscript once again. The Authors have not addressed all the suggestions made in the previous revision. The following are my comments:
Introduction: The authors include other important information and data, but they do not give the information why it is necessary to investigate whether some factors (age, gender, mRS) influence the decision to activate the VVAVC;
Methods: i) the study design is not clear (is it retrospective or cross-sectional? - it seems to be a retrospective study); ii) where were the data collected? (from medical records?); iii) in the statistical analysis, it is necessary to indicate the level of significance (0.05?); also, the following sentence is not clear: "Effect sizes were calculated to ascertain the findings’ practical significance and statistical significance". In the tables, the authors have reported the "residuals", but no information is provided in the statistical consideration.
Results: row#154: please specify when patients were asymptomatic.
Limitations: I do not understand why the lack of recent studies on stroke in Portugal is a limitation. It is a strength.
Other minor comments:
It is necessary to make the use of the terms 'sex' and 'gender' consistent in the text. In my opinion it is more appropriate the term 'gender'.
Pay attention to the use of . for decimals and thousands (line #259: the authors wrote 6.194 instead of 6,194 - please check the whole manuscript).
I suggest that Authors read the manuscript carefully.
Comments on the Quality of English Languageok.
Author Response
Dear Reviewer,
We would like to express our great gratitude to your second reviewing and for your precious comments on it. In this letter, we provide a point-by-point reply to all issues raised in review comments. We hope that we have been able to address all issues in an adequate way.
Introduction
R: We added to the text: “Additionally, and accordingly to the fact that older and disabled patients are typically not considered for intravenous thrombolysis (IVT) treatment due to concerns about poor outcomes, despite recent stroke guidelines and studies suggesting that IVT may be reasonable for patients over 80 years old and those with previous Modified Rankin Scale (mRS) score of ≥2, with some studies showing favourable outcomes and significant neurological improvement compared to untreated patients [14-21]. This study also aims to investigate whether factors such as the previous mRS score, age, and gender influence the decision to activate the VVAVC.”
Methods:
- i) the study design is not clear (is it retrospective or cross-sectional?
R: We changed the study design to “retrospective study”.
- ii) where were the data collected?
R: We changed the text to “The data for this study was collected from the patient's medical and nursing records and provided by the institution in an EXCEL® file format (Microsoft Corporation, Redmond, WA)”
iii) in the statistical analysis, it is necessary to indicate the level of significance (0.05?)
R: We added to the text “ A p-value of <0.05 was considered statistically significant”.
- iv) also, the following sentence is not clear: "Effect sizes were calculated to ascertain the findings’ practical significance and statistical significance".
R: We deleted the phrase.
- v) In the tables, the authors have reported the "residuals", but no information is provided in the statistical consideration.
R: We changed the text to: “The distribution of residual values in Table 1, with all values falling between -1.96 and 1.96, which is statistically not significant, further confirmed this.
We added the text :“In 2021, the frequency of activations at the triage was lower than expected (residual=-2.8), while in 2022, the frequency of triage activations was higher than expected (residual=2.8). A similar situation occurred with non-activations, where in 2021 the frequency was higher than expected (residual=2.5), while in 2022 the frequency was lower than expected (residual=-2.5). In both situations, the data is statistically significant (Table 3).”
- vi) Results: row#154: please specify when patients were asymptomatic.
R: We changed the text to “Regarding the previous mRS score, before the ED episode, 159 patients (70.4%) were asymptomatic. This distribution was consistent across both years.”
vii) Limitations: I do not understand why the lack of recent studies on stroke in Portugal is a limitation. It is a strength.
R: We changed the text to: “Firstly, there is a lack of recent research on stroke in Portugal, and current statistical data on the prevalence and incidence of stroke are insufficient. This limitation hinders the comparison of data, but it also makes the study pioneering, relevant, and a way to improve care for stroke patients.
Additionally, the absence of data on pre-hospital VVAVC activations made it impossible to determine the impact of pre-hospital activation on door-to-CT time. This highlights the importance of establishing a centralized stroke database in Portugal to track stroke care from symptom onset to long-term follow-up.”
viii) It is necessary to make the use of the terms 'sex' and 'gender' consistent in the text. In my opinion it is more appropriate the term 'gender'.
R: All occurrences of "sex" were uniformly replaced with "gender".
- ix) Pay attention to the use of for decimals and thousands (line #259: the authors wrote 6.194 instead of 6,194 - please check the whole manuscript).
R: We changed the text to “Regarding pre-hospital VVAVC activations in Portugal, Lavinha's (2019) [20] study discovered that the number of pre-hospital VVAVC activations was only 6,194 (12.97%).”
We read and corrected the errors in the manuscript.
The changes in the revised manuscript are highlighted in grey.
Author Response File: 
Author Response.pdf
