This observational study investigates the prediction of pressure injury (PI) education within 24 hours of patient hospital admission to an acute care setting. This is an interesting study that explores an important topic in the field of PI prevention which carries important implications for clinical practice. The percentage of participants receiving PIP education was very low (5.7%, n=17), which is a key finding of this study. While BMI emerged as a statistically significant predictor, its clinical significance is difficult to determine due to the small number of observations receiving PIP education. This limitation highlights the need for further research with larger sample sizes to better understand the relationship between BMI and PIP education. The following comments are provided for the authors to consider as they revise their manuscript:

Abstract: The abstract is very short and would recommend expanding on the methods and results to provide a more comprehensive overview of this study for the readers. When reporting % in the results section, could the authors also provide the number of observations (n=). Conclusion starts with “continued low levels” is this referring to a different study? I would recommend focusing the conclusion solely on the findings of this study.

Implications for professional practice and/or patient care:
I would reconsider the bullet points here. The key takeaway of this study is that there was a very low percentage of patients that received PIP education. Providing patient education for PIP in hospital is vital and essential for placing the patient at the centre of their care. Education is also needed to deliver personalised preventative strategies based on patient needs, preferences and values. This also helps to promote self-care and autonomy for PI prevention at home which is an important consideration following hospital discharge, as the risk of developing a PI extends into the community setting.
While the authors have written “patients with a higher BMI can have an increased PI risk due to reduced mobility” – it should be acknowledged that this is one factor to consider among a complex interplay of competing factors that increase the likelihood of an individual developing a PI.

This study did not assess predictor variables for PI development and thus the second implication for practice “early education for patients with increasing BMI may encourage help-seeking and repositioning…….sacrum and heels” should be re-considered.
(impact) While understanding that those with higher BMI received more education, it is not clear within the manuscript how this improves nursing care strategies, other than the need to improve education for patients at risk of developing PIs.
Reporting method: should this include the STROBE guidelines here?

Introduction: Please correct the definition of PI as per the cited international clinical practice guideline.
Background: Please expand further on risk assessment and risk factors, brining in a wider body of literature to this section. The same references are frequently being used throughout. It is important to acknowledge that while PI development is multifactorial in nature, mobility/activity is an independent predicator of risk.
Knowledge and attitudes of healthcare professionals goes hand in hand when it comes to delivering PI preventative strategies– this should also be considered. Advise also bringing in further international literature exploring PIP education to patients across different hospital settings – this will provide further context for why it is important to conduct the present study.

Methods: After reading this manuscript this seems to be a cross sectional study design as the information was collected during one time point only for each participant.
Section 3.1. Is it possible to be more precise when describing the organisational, clinical and patient factors alongside the rationale for the inclusion of these variables? It would be good to understand how the final 9 predictor variables were decided upon.
Section 4.1 – Semi-structured observations – could the authors expand further on this with what was structured and if any prompts were provided to help participants answer the questions.
“sub-sample of patients who were assessed as being at-risk” is this as defined by the Waterlow score?
The sub-sample was drawn from 2/3 sites due to the similarities between the hospitals, is there a rationale why all three sites were not included?
Section 4.4. Is there a reason criteria number 3/4 “existing sacral PI, sacral skin injury, allergy or lesion on hospital admission” and “patients with urinary/faecal incontinence” is an exclusion for participation in this study?
Section 4.5: Was the data from sub-categories of Waterlow scores for all participants also collected?
4.7 – While the exploratory model-building approach allows for the identification of potential predictors and relationships, it comes with limitations that should be acknowledged.

Results:
Table 3: Is it possible to included risk categories of Waterlow risk assessment score (high risk/very high risk) and sub-categories of the Waterlow (i.e. mobility/malnutrition etc)
Was PI development also collected? It would be good to know if PIP education had an impact on PI development.
Section 5.2. Field notes obtained from 26 participants. Is there a reason why there was a small number?
While the authors acknowledge the inability to undertake a full thematic analysis, is it possible to include more qualitative data collected?

Discussion section 6.3: Did the authors collect data related to organisational culture or nurse related factors? It is not clear when reading the methods/results of this study.
When discussing organisational barriers, it would be good to elaborate on what the barriers are specifically?
This study was conducted within two Australian hospital settings and the discussion/introduction is heavily focused on the Australian population. As this is an international journal I would recommend including more international study data on this topic area for targeting a wider healthcare audience.

Section 6.5: It is mentioned that control group patients were included and they do not know if the intervention group received PIP education. What was the intervention group assigned to in the original RCT?
Recommendations for future research: This study did not explore the time constrains and competing priorities in the first 24 hours of a patient’s admission. This could be a discussion point as opposed to a recommendation arising from this study. If this is a recommendation it should be explicitly stated that future research should explore the barriers and facilitators to providing PIP education with the first 24 hours of patient hospital admission (as an example). If recommending future predicting factors, would the authors recommend including different or more predictor variables in future research?

Dear authors,

Thank you for taking the time to revise this manuscript and respond to each of the reviewer’s comments. My main concern related to this paper is that presenting these findings in isolation to the parent trial prevents readers from having adequate context and I would question the rationale for why these findings are not being reported with the data from the wider study.

The key reported finding was that patients with a higher BMI are more likely to receive education - however it is not clear how this finding alone helps nurses to make more informed choices about their pressure injury prevention care which is what the authors have highlighted as an implication for practice/patient care.

Ultimately while BMI was included as a variable of interest, there were other important variables for PI risk that were not considered in this study.
Another concern raised during the previous review is that at-risk patients were excluded from this study (i.e. existing PI, incontinence) which is an important limitation. Another important limitation is that sub-categories of Waterlow scores were not reported, as this would provide further understanding of the baseline demographics and risk factors of the included participants.

The authors have also indicated that the research nurse did not ask patients about their perceptions on the PIP education, and thus this was collected on an "ad hoc" basis as it wasn't part of the planned data collection. Collecting "voluntary anecdotal comments offered by patients" and reporting that a thematic analysis was not undertaken due to insufficient data raises further questions about this data and questions if conclusions can/should be drawn from this data.

Based on my previous comment, the authors have changed organisational barriers to contextual factors, however I’d like to question how hospital site alone is a sufficient contextual factor.

Thank you for taking the time to address the reviewers comments. The manuscript has improved and I have noted a few minor comments for the authors consideration which I have outlined below.

(1). Mobility has been added throughout as an important independent predicator of PU risk, however, activity and mobility should be considered together as opposed to in isolation of each other in terms of PU development.

(2).. As the background has been revised to specify that "engaging patients and caregivers in PIP education during their hospital admission is recommended by international clinical guidelines" (page 4, line 17) - to further enhance this sentence I would recommend the inclusion of the aSSKINg framework, which includes "giving information" as a fundamental component of PU care bundles.

Martin S, Holloway S. Pressure ulcers: aSSKINg framework study. Br J Community Nurs. 2024;29(Sup6): S16-s22.

(3) Page 4 line 43 "patients are should receive PIP education" Please remove are from this sentence.