The Influence of COVID-19 on Patient Mobilization and Injury Attributes in the ICU: A Retrospective Analysis of a Level II Trauma Center

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors

You report on a pre- and post-Covid cohort of trauma patients in terms of PT and mobilization and find that while the post-Covid cohort were older, had more females and higher injury severity there was a major difference in outcomes measured, with higher complications and mortality. There was however no difference in time to mobility and PT consult.

The introduction is succinct and valid.

The methods are appropriate and very detailed, ethical aspects addressed.

The results are presented in prose with useful tables and graphs, although I feel the two supplemental tables should be in the main document.

The Discussion summarizes the key findings and places these in the context of the existing knowledge, however appears to focus on American literature and I would recommend that some of the international trauma-Covid papers be considered for inclusion (There were many from South Africa, Bangladesh, Europe and China to name a few places). This would place the paper in international context.

Minor points:

1) "Traumatically injured" appeas to be an American tautology - preferably state "trauma patients" or "injured patients" throughout

2) Add the two supplemental tables to the main paper

3) Add some more international papers to the discussion - where relevant to place the paper in international context.

Thanks for allowing me to review your work.

Comments on the Quality of English Language

Minor terminology change requested to aviod the tautology of "traumatically injured".

Author Response

Thank you for kindly reviewing our manuscript. We have addressed each of our comments and provided a response to each below. 

1) The Discussion summarizes the key findings and places these in the context of the existing knowledge, however appears to focus on American literature and I would recommend that some of the international trauma-Covid papers be considered for inclusion (There were many from South Africa, Bangladesh, Europe and China to name a few places). This would place the paper in international context.

Thank you for this recommendation. We have added several international references to the Discussion. 

Minor points:

• "Traumatically injured" appears to be an American tautology - preferably state "trauma patients" or "injured patients" throughout

We have made this change throughout

• Add the two supplemental tables to the main paper

We incorporated the supplemental tables into the main paper

• Add some more international papers to the discussion - where relevant to place the paper in international context.

Thank you again for this recommendation, we’ve added several sentences to the Discussion.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you very much for your well-written manuscript, dealing with an interesting medical issue, which is the impact of the COVID-19 pandemic on the quality of hospital care of non-COVID patients (in this case patients with traumatic injury as a principal reason for their ICU admission). Please pay attention to the following questions and queries, pertaining to your manuscript:

1.      Please provide a Flow Chart of your study population. The visualization of the included and excluded patients and their classification will enhance the reading quality of your manuscript.

2.      Line 97. Instead of “Chief complaints” I rather suggest: “Chief mechanisms of injury”. Accordingly, please also in Table 1.

3.      Line 100. Please provide the full meaning of the abbreviation ER on first appearance in the text (emergency room, line 64).

4.      Line 115: “possesses an advanced directive, inability to perform”: I suppose that the coma between the words directive and inability should be deleted as unnecessary.

5.      Line 117: “born prematurely”, children also included to your study?

6.      Line 128: “all trauma patients that that were admitted”: “that” was used twice.

7.      Line 319: “symptoms As such»: please add the missing full-stop.

8.      General Comment: the main objective of the study was to compare the presence and the quality of mobilization in ICU trauma patients before and during the COVID-19 pandemic. The only parameters taken in account for this purpose were: mobilized or not and days to mobilization after ICU admission. No additional information has been provided regarding the frequency of mobilization (daily or not), the mean duration of mobilization per patient and the type of mobilization (passive, active, in bed, on the floor etc.). This additional information is though essential in order to assess the quality of the mobilization protocols before and during the pandemic. Optionally please add this information to your manuscript. If not available, please discuss as limitation.

Best Regards

Comments on the Quality of English Language

Moderate changes

Author Response

We thank the reviewer for carefully considering our manuscript and for the helpful comments. Please find our responses below and we've highlighted changes to the manuscript document throughout. 

1. Please provide a Flow Chart of your study population. The visualization of the included and excluded patients and their classification will enhance the reading quality of your manuscript.

Thank you for this recommendation! We’ve now included Flowchart 1-2 highlight Inclusion Criteria and Study Population Classification

2. Line 97. Instead of “Chief complaints” I rather suggest: “Chief mechanisms of injury”. Accordingly, please also in Table 1.

We have made this change to Tables 2 and 6

3. Line 100. Please provide the full meaning of the abbreviation ER on first appearance in the text (emergency room, line 64).

We have made this change

4. Line 115: “possesses an advanced directive, inability to perform”: I suppose that the coma between the words directive and inability should be deleted as unnecessary.

We alter the text to match the entire comorbidity phrasing “possesses an advanced directive limiting care”. The Advance directive limiting care is now consistent with terminology in the Comorbidity Tables 3 & 7

5. Line 117: “born prematurely”, children also included to your study?

This phrase was removed, and "Prematurity" removed from the Comorbidity tables 3 & 7. There were notes in the medical chart that a patient was born prematurely. However, this level II trauma center only handles patients 16 and older. Those admitted 15 years of age or younger are transferred to a nearby level I trauma center. There was only 1 adult patient in our study population that was noted as being born prematurely. 

6. Line 128: “all trauma patients that that were admitted”: “that” was used twice.

Thank you for catching this. It has been removed

7. Line 319: “symptoms As such»: please add the missing full-stop.

This has been fixed

8. General Comment: the main objective of the study was to compare the presence and the quality of mobilization in ICU trauma patients before and during the COVID-19 pandemic. The only parameters taken in account for this purpose were: mobilized or not and days to mobilization after ICU admission. No additional information has been provided regarding the frequency of mobilization (daily or not), the mean duration of mobilization per patient and the type of mobilization (passive, active, in bed, on the floor etc.). This additional information is though essential in order to assess the quality of the mobilization protocols before and during the pandemic. Optionally please add this information to your manuscript. If not available, please discuss as limitation.

Thank you for your comment. We’ve defined mobilization in the Methods section and added another limitation sentence to the Discussion. 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for addressing the points raised - the paper is much improved.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

thank you for providing comprehensive and convincing answers to the questions and queries, expressed by me and the other reviewers, and made changes that have contributed to quality improvement and increased the publishing potential of your work. I have no further points to denote.

Best Regards