Review Reports - Mitigating Risks in Hospital Facilities—An Analysis of the Relationship Between Healthcare Risks and the Built Environment: A Literature Review and Survey in the Italian Scenario

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The study presented for evaluation is an interesting analysis of the issue, which may have a significant impact on the organization of patient care in the field of prevention of adverse events in the hospital. However, it requires changes. Introduction - is very general, does not contain references to specific data, only a general description of the significance of the problem. Methods - no information on the method of analysis of quantitative data collected based on the questionnaire included in the appendix Results - no reference in the text to tables and figures in the manuscript. In the results section, there is no statistical analysis of the obtained data - only the percentage share of variables is indicated - this requires correction. In addition, the results should be grouped and illustrated with selected figures so that the work is clear to the reader. References are not prepared in accordance with the record expected by the publisher.

Author Response

REPLY TO REVIEWER 1

Thank you very much for your valuable and constructive feedback. Your insightful comments have helped us improve the quality and clarity of our manuscript. We sincerely appreciate the time and effort you dedicated to reviewing our work.

On behalf of all authors, please find the detailed responses below and the corresponding revisions highlighted/in track changes in the re-submitted files.

Point-by-point response to Comments and Suggestions for Authors

Comment 1: Introduction

[Introduction - is very general, does not contain references to specific data, only a general description of the significance of the problem.]

Response 1:

We categorize the referenced sources (e.g., “WHO guidance” and “peer-reviewed studies”) when first mentioned to help readers assess the reliability of the information. This part is focused on explaining the main categories of risks associated to the built environment and there is no others significant data to add in this part. We also add to the HAI some examples of the main infectious agents associated with hospital-acquired infections. The last paragraph it’s clearer for evidence the aim of the study.

Comment 2: Methods

[no information on the method of analysis of quantitative data collected based on the questionnaire included in the appendix]

Response 2:

We have revised the Materials and Methods section to include a clear explanation of the quantitative data analysis regarding the survey part. Specifically, all responses from the structured questionnaire were analyzed using descriptive statistical methods. Frequencies and proportions were calculated manually and verified using Microsoft Excel. Given the small sample size (n = 9 hospitals), no inferential statistical tests were applied, in line with the exploratory nature of the study. This clarification has now been incorporated into the manuscript (see Section 2.2, paragraph 3).

Comment 3: Results

[Results - no reference in the text to tables and figures in the manuscript. In the results section, there is no statistical analysis of the obtained data - only the percentage share of variables is indicated - this requires correction.]

Response 3:

Thank you for pointing this out. The reference to tables and figures has been add in the text to tables and figures in the manuscript. We add the statistical information about the obtained data.

Comment 5: Reference

[References are not prepared in accordance with the record expected by the publisher.]

Response 5:

Thank you for your comment. The references have been revised and reformatted to comply with the publisher’s required citation style. All entries have been checked for consistency, including author names, publication years, journal titles, volume and issue numbers, page ranges, and DOI links where applicable.

Reviewer 2 Report

Comments and Suggestions for Authors

“Mitigating risks in hospital facilities. An analysis of the relationship between healthcare risks and the built environment” is an interesting topic, but unfortunately, the content is not well written and presented, the paper needs major revisions.

Here are the main comments that should be considered__

Abstract

Abstract reflects the whole manuscript; it needs to be completely revised to meet the quality of a scientific article. In the current version, lack of methodological detail, issues with structure and clarity the authors do not specific details of results (please write key findings or quantitative insights that would significantly enhance the value of the abstract), instead, only introductory aspects are presented.

Revise the conclusion also, the conclusion identifies a gap but does not offer a clear implication.

Introduction

Does not set a problem and the need for this work properly. What has been done and what information is missing?

The authors have included unnecessary information which is not appropriate in this section. This information may be succinctly added to the discussion when describing facts and comparing with the previous data. Many things are repeated and elaborated unnecessarily.

Put some references and describe your country data published from previous studies.

Briefly categorize the referenced sources (e.g., “WHO guidance,” “peer-reviewed clinical studies,” etc.) when first mentioned to help readers assess the reliability of the information.

Materials and Methods

There is no mention of how many documents were identified, screened, included, or excluded. A PRISMA flow diagramis recommended to add to this manuscript.

Include a brief description of the questionnaire design, the details of hospitals involved (you only mentioned healthcare facilities, and the intended outcome (e.g., risk profiling etc.).

Describe inclusion criteria for hospital selection and explain regional focus (e.g., why only Northern Italy?).

Provide the questionnaire as supplementary materials.

No ethical approval statement is provided?

Result

The data interpretation is well presented, but the statistical significance of the obtained data is little needed to improve. Please get some references from Global Burden of Disease (GBD) studies and discuss in “Discussion”.

Discussion_ it would have better if you compare your study or at least discus these facts more in the discussion part. “Seems only directed, I am sorry, but no comprehensive report exists for several important reasons specified.” The comparison of data obtained in the present study to published data should be added along with the clear description of what new the present study adds to the current knowledge, a more detailed exposition of the points for a deeper understanding would be desirable.

Current scenarios for potential effects of the COVID-19 pandemic and the other potential impact of improvements preferentially targeting all ages survival due to this risk factor, you have mentioned in the results and nowhere I found in discussion. Could you please provide some links between your result with related previous papers.

Conclusion

The conclusion does not provide aspects mentioned in the title and body of the text as epidemiological perspectives, and clinical and diagnostic advances, and future plan according to socio-demographic predictor variables. You can merge the conclusion with “Future development”.

Author Response

Response to Reviewer 2 Comments

Summary

On behalf of all authors, please find the detailed responses below and the corresponding revisions highlighted/in track changes in the re-submitted files.

Point-by-point response to Comments and Suggestions for Authors

Comment 1: Abstract

[Abstract reflects the whole manuscript; it needs to be completely revised to meet the quality of a scientific article. In the current version, lack of methodological detail, issues with structure and clarity the authors do not specific details of results (please write key findings or quantitative insights that would significantly enhance the value of the abstract), instead, only introductory aspects are presented.]

Response 1:

The abstract has been revised according to the requested upgraded.

Comment 2: Introduction

[Does not set a problem and the need for this work properly. What has been done and what information is missing?

Put some references and describe your country data published from previous studies.

Briefly categorize the referenced sources (e.g., “WHO guidance,” “peer-reviewed clinical studies,” etc.) when first mentioned to help readers assess the reliability of the information.]

Response 2:

Comment 3: Materials and methods

[There is no mention of how many documents were identified, screened, included, or excluded. A PRISMA flow diagramis recommended to add to this manuscript.

Include a brief description of the questionnaire design, the details of hospitals involved (you only mentioned healthcare facilities, and the intended outcome (e.g., risk profiling etc.).

Describe inclusion criteria for hospital selection and explain regional focus (e.g., why only Northern Italy?).

Provide the questionnaire as supplementary materials.

No ethical approval statement is provided?]

Response 3:

Thank you for your valuable comment. Regarding the first point, we confirm that the information related to the number of documents identified, screened, included, and excluded was already present in the preliminary results section. However, for greater clarity and methodological consistency, this information has now been moved and integrated into the Methodology section, paragraph 2.1.

Additionally, the questionnaire has been described in detail in paragraph 2.2 of the Methodology. The full version of the questionnaire has been included in Annex B as supplementary material.

The ethical approval statement is not required.

Comment 4: Results and Discussion

[The data interpretation is well presented, but the statistical significance of the obtained data is little needed to improve. Please get some references from Global Burden of Disease (GBD) studies and discuss in “Discussion”.

Discussion_ it would have better if you compare your study or at least discus these facts more in the discussion part. “Seems only directed, I am sorry, but no comprehensive report exists for several important reasons specified.” The comparison of data obtained in the present study to published data should be added along with the clear description of what new the present study adds to the current knowledge, a more detailed exposition of the points for a deeper understanding would be desirable.

Response 4:

Thank you for pointing this out and for your suggestion. We add some references from Global Burden of Disease (GBD) studies, the one on the AMR, and add it the discussion. As requested, a comparison has been made between the data obtained in this study and those available in the existing literature, clearly highlighting the discrepancies between recommended design strategies and those implemented in the analysed healthcare facilities. Furthermore, the original contribution of this study within the current body of knowledge has been explicitly stated, emphasizing how the results provide an updated overview of infrastructural challenges in hospitals in Northern Italy and underline the need for targeted actions to bridge the gap between theory and practice. The discussion section has been expanded to offer a more detailed exposition of the key points, to support a deeper understanding of the design implications related to risk management in healthcare settings.

Comment 5: Conclusion

[The conclusion does not provide aspects mentioned in the title and body of the text as epidemiological perspectives, and clinical and diagnostic advances, and future plan according to socio-demographic predictor variables. You can merge the conclusion with “Future development”.]

Response 5:

The conclusions have been integrated by drawing on parts of the main text, with the aim of more clearly highlighting the future actions to be undertaken based on the strategies necessary for the hospital projects.

Reviewer 3 Report

Comments and Suggestions for Authors

I have reviewed the manuscript “Mitigating risks in hospital facilities. An analysis of the relationship between healthcare risks and the built environment.” by Beatrice Pattaro and coauthors. The authors conducted a literature review to identify risks associated with hospital architecture. Based on the information obtained, they developed a questionnaire and assessed the current status of hospitals in Italy. The study addresses an important aspect of healthcare. However, the second part of the study is quite limited (only nine Italian hospitals). This restricts the scope and the firm identification of points to consider in hospital management. Other areas for improvement are detailed below.
Title
• I suggest changing it to indicate the restriction on hospitals in Italy.
Introduction
• Lines 48-50: I suggest adding some examples of the main infectious agents associated with hospital-acquired infections. For example, highlighting the ESKAPEE group.
• I suggest adding a short paragraph pointing out the differences in hospital risks at the geographic level caused by socioeconomic, political, or other factors.
• The study's objectives should be clear and measurable. I recommend rewording the last paragraph to avoid words like "understand" or "to map," which don't clearly evidence the results.
Methods
• Section 2.2.: At the end of this section, it must be indicated how the descriptive analysis will be carried out and the form of presentation of results (percentages, means, proportions, ratios, ...)
Results
• Line 155: The mentioned 1977 documents in Scopus are not in agreement with what is shown in Fig. 1.
• Literature Review: The authors indicate that they identified 25 papers after filtering their search. For transparency reasons, they should provide this list, even if only as supplementary material, and cite all of them in the relevant section of the manuscript.
• Line 223: Indicate the meaning of HVAC in detail.
• Flexibility for Emergencies (lines 250-257): While it is true that COVID-19 is a relevant milestone in this context, it is important to bring to the reader additional figures and potential contexts caused by other pathogens with different transmission behavior and environmental resistance (i.e. pox, influenza, ...).
• Section 3.2.2: I recommend placing the raw numbers next to each mention of their percentages. i.e. "...Only 22% (2/9 or n=2) of hospitals reported...".
• Most figures and tables were not referenced in the body of the manuscript. This should be verified and included.
• Many of the figures are redundant and unnecessary (Fig. 4 through Fig. 14) with the data described in the results and should be removed.
Discussion
• This section is deficient and notoriously insufficient. The authors point to the main observations obtained from the results. However, authors should debate and support these ideas with existing literature.
• Additionally, there is little mention of structural/organizational limitations of hospitals as barriers to implementation that must be addressed.
• The discussion lacks comparison with other countries or international benchmarks; this would strengthen the generalizability.
• The limitations of the survey sample are acknowledged, but the discussion does not address how these limitations might affect the conclusions.
• The authors could better contextualize findings within a systems approach to hospital design. How do these design deficits affect patient outcomes or healthcare costs?.

Author Response

Response to Reviewer 3 Comments

Summary

On behalf of all authors, please find the detailed responses below and the corresponding revisions highlighted/in track changes in the re-submitted files.

New title: Mitigating risks in hospital facilities. An analysis of the relationship between healthcare risks and the built environment: Literature review and survey in the Italian scenario.

Point-by-point response to Comments and Suggestions for Authors

Comment 1: Introduction

[• Lines 48-50: I suggest adding some examples of the main infectious agents associated with hospital-acquired infections. For example, highlighting the ESKAPEE group.
• I suggest adding a short paragraph pointing out the differences in hospital risks at the geographic level caused by socioeconomic, political, or other factors.
• The study's objectives should be clear and measurable. I recommend rewording the last paragraph to avoid words like "understand" or "to map," which don't clearly evidence the results.]

Response 1:

Thank you very much for your valuable feedback. I included examples of the main infectious agents, specifically highlighting the ESKAPEE group, to better contextualize the discussion on hospital-acquired infections. I revised the study’s objectives to make them more precise and measurable, avoiding vague terms like “understand” or “to map.”

Comment 2: Methods

[• Section 2.2.: At the end of this section, it must be indicated how the descriptive analysis will be carried out and the form of presentation of results (percentages, means, proportions, ratios, ...)]

Response 2: We have revised the final paragraph of Section 2.2 to clarify the approach used for the analysis of the survey data. The results are presented in the form of absolute frequencies (n) and relative percentages (%) to illustrate the distribution of responses across the participating hospital facilities. Given the limited sample size and exploratory nature of the study, no inferential statistics were applied. This information has now been added to the manuscript for transparency and clarity.

Comment 3: Results

[• Line 155: The mentioned 1977 documents in Scopus are not in agreement with what is shown in Fig. 1.
• Literature Review: The authors indicate that they identified 25 papers after filtering their search. For transparency reasons, they should provide this list, even if only as supplementary material, and cite all of them in the relevant section of the manuscript.
• Line 223: Indicate the meaning of HVAC in detail.
• Flexibility for Emergencies (lines 250-257): While it is true that COVID-19 is a relevant milestone in this context, it is important to bring to the reader additional figures and potential contexts caused by other pathogens with different transmission behavior and environmental resistance (i.e. pox, influenza, ...).
• Section 3.2.2: I recommend placing the raw numbers next to each mention of their percentages. i.e. "...Only 22% (2/9 or n=2) of hospitals reported...".
• Most figures and tables were not referenced in the body of the manuscript. This should be verified and included.
• Many of the figures are redundant and unnecessary (Fig. 4 through Fig. 14) with the data described in the results and should be removed.]

Response 3:

Thank you for pointing that out. The figure has been revised to ensure greater clarity and consistency with the data referenced in the text. We have adjusted it so that it accurately reflects the number of documents mentioned in Scopus, making the information clearer and more intuitive for the reader.
Thank you for your suggestion. To enhance transparency, we have included the full list of the 25 papers identified after filtering as Appendix A.
We have now written out the full term for HVAC (Heating, Ventilation, and Air Conditioning) in the manuscript to ensure clarity for all readers.
We have addressed this point by adding a paragraph emphasising that hospital design and infrastructure should support long-term preparedness not only for pandemics such as COVID-19, but also for a wider range of disease outbreaks caused by pathogens with different modes of transmission and environmental resistance, such as smallpox and influenza. The text also highlights the need to consider natural events that may lead to public health emergencies.
We have now included the raw numbers alongside each percentage as recommended, to improve clarity (e.g., “22% (n=2)”). Additionally, all figures and tables are now properly referenced within the body of the manuscript.

Comment 4: Discussion

[• This section is deficient and notoriously insufficient. The authors point to the main observations obtained from the results. However, authors should debate and support these ideas with existing literature.
• Additionally, there is little mention of structural/organizational limitations of hospitals as barriers to implementation that must be addressed.
• The discussion lacks comparison with other countries or international benchmarks; this would strengthen the generalizability.
• The limitations of the survey sample are acknowledged, but the discussion does not address how these limitations might affect the conclusions.
• The authors could better contextualize findings within a systems approach to hospital design. How do these design deficits affect patient outcomes or healthcare costs?.]

Response 4:

Thank you very much for your detailed and constructive feedback. In response, the discussion section has been completely revised in line with your recommendations. The revised text now makes clear links to the literature review and supports key findings with relevant and up-to-date sources.

Key observations from the findings are now discussed in the context of the existing literature, highlighting consistencies and discrepancies.

We have included reflections on the structural and organisational limitations of hospitals as barriers to the implementation of recommended strategies. The limitations of the survey sample are acknowledged and now explicitly discussed in terms of their potential impact on the conclusions. The findings are contextualised within a systems approach to hospital design, outlining how current design deficiencies may affect patient outcomes and healthcare costs.

These revisions aim to improve the depth and relevance of the discussion, ensuring that it is well supported by the literature and aligned with the aims of the study.

Reviewer 4 Report

Comments and Suggestions for Authors

The manuscript is relevant and shows important results in the area of population health by examining the role of the built environment in risk mitigation in healthcare facilities, with a specific focus on how hospital infrastructure can influence and improve the safety of patients, staff and visitors. The data highlighted possible risk mitigation strategies applicable in healthcare facilities, as well as what is supported by recent scientific research and what has been implemented in Italian hospitals. Furthermore, it highlights the need for improving the quality of healthcare facilities and minimizing risks with an international approach.

Author Response

Thank you for your thoughtful and constructive feedback. We are pleased to know that the manuscript was recognised as addressing an important issue and that key elements such as the abstract, introduction, methodology and results were well received.

Reviewer 5 Report

Comments and Suggestions for Authors

The topic falls within the scope of the journal and addresses an extremely important issue. The abstract is well written, and the introduction provides a solid foundation for the study. The aim of the paper is clearly defined. The methodology is described in detail, and the results are clearly presented. Research findings on hospital risks such as hospital-acquired infections, patient falls, safe environments, and more indicate the need for comprehensive strategies. The literature review highlights the importance of the hospital environment and its role as a potential source of risk for patients. Hospital-acquired infections are described in detail, along with measures for their prevention and control. Additionally, the review emphasizes the significance of technical adaptations of the hospital environment.

Author Response

In response to your comments, we have undertaken a thorough revision of the manuscript to improve the overall quality of the English language. Particular attention has been paid to improving clarity, coherence and academic tone throughout the text. We have carefully refined the phrasing, grammar and structure to ensure that the content is communicated as effectively and professionally as possible. We hope that these revisions will contribute to a smoother reading experience and better reflect the quality of the research presented.

We sincerely appreciate your insights, which have helped us to strengthen the manuscript.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

I appreciate the authors; they have improved the quality of the manuscript for wider dissemination of the findings and broader readership. Now I recommend this revised manuscript for publication.

Author Response

Thank you for your kind words and for recommending our revised manuscript for publication. We greatly appreciate your time, careful evaluation and constructive feedback throughout the review process. Your insights have been invaluable in helping us to improve the quality and clarity of our work.

Reviewer 3 Report

Comments and Suggestions for Authors

The authors have addressed all the comments made in the first round of revisions, and the manuscript is noticeably improved.

However, I still consider Figures 4 through 14 to be redundant with the text and should be removed.

Author Response

Thank you for your thoughtful and constructive review. We sincerely appreciate the time and effort you took to evaluate our manuscript. Your comments have been very helpful in improving the overall quality and clarity of the paper.

We have carefully considered your comments regarding Figures 4-14. As a result, we have made a thorough revision and decided to remove several figures between 1 and 14. We have retained only those that we believe are essential to effectively highlight the key results and support the main findings of the study. This revision has allowed us to streamline the manuscript and improve its readability, while maintaining the completeness and integrity of the data presented.