Study design and sampling pool

This was a single-site pilot prospective implementation study. A mixed methods approach guided by the theoretical framework of acceptability [12] and the implementation framework proposed by Peters et al., [13] was used to evaluate pathway implementation outcomes. The sampling pool included staff who delivered care and patients who received care according to the pathway. Evaluation included collection of implementation and outcome information, patient demographic and clinical data and patient semi-structured interviews, a staff survey and staff focus group.

Setting

This study was conducted across the acute and rehabilitation wards of the Victorian Spinal Cord Service, a statewide service for individuals who experience traumatic SCI. Care pathway components were delivered based on scheduled timeframes rather than ward location, as patients moved variably between acute and rehabilitation settings- including possible transfers back to acute care.

Ethics approval and consent

Ethics approval was received from the Human Research Ethics Committee (HREC/75733/Austin 2022). Patients gave verbal, witnessed informed consent to participate in the care pathway and additional verbal consent to participate and for audio recording of the interview. Clinician participants in the focus group provided written informed consent and completion and return of the survey implied clinicians’ consent. All methods were performed in accordance with the relevant guidelines and regulations.

Development of the ATSCI-nut pathway

The project team [dietitians, exercise physiologist (EP) and body composition experts] designed the ATSCI-nut care pathway based on clinical practice recommendations, guidelines [1, 3, 4] and recent research [7, 9,10,11]. The AACTT framework was used to help define behaviours and components of care within the pathway [6].

Components considered within the pathway to support initiation of appropriate clinical care processes and sustainable implementation included:

screening and referral processes;

setting specific actions or behaviours;

specifying who is to conduct each action and on whom the actions are performed;

timelines for clinical processes including screening, assessment and treatment and; definition of assessments to be administered when and by whom.

Local barriers and enablers to implementing the pathway were identified and considered. Supplementary Table 1 summarises clinical practice guidelines, and the recent literature mapped to the AACTT framework [6]. Figure 1 illustrates the ATSCI-nut care pathway.

Fig. 1

Acute Traumatic Spinal Cord Injury (ATSCI-Nut) Pathway.

Implementation strategies

The implementation strategies utilised are reported according to the Expert Recommendations for Implementing Change (ERIC) study classifications [14].

Train and educate stakeholders

Dietitians and an EP completed an education program and a BIS competency package developed by the study lead. This included an overview of the care pathway and BIS methodology, observing the study lead conducting BIS, completing BIS with the study lead, followed by independently completing BIS with the study lead observing.

Support clinicians

The study lead was present for BIS measurements until the staff member felt confident and was competent to complete measurements independently.

Develop stakeholder interrelationships

The project team met monthly during the first six months of implementation. The multidisciplinary ward newsletter and Quality Improvement Committee were used to communicate project updates prior to study commencement, at the end of recruitment and study cessation.

Use evaluative and iterative strategies

A continuous quality improvement feedback cycle was used to make immediate adjustments to the care pathway processes.

Change infrastructure

The care pathway was included in a local nutrition clinical guideline. Additional strategies used after the initial implementation included development of a spreadsheet to track dates body composition measurements were due and clarification of processes when patients transferred between campuses.

Engage consumers/adapt and tailor the content

Plotting and printing body composition trends was introduced following patient reports of poor communication about body composition results.

Pilot test the feasibility of the ATSCI-nut care pathway

The care pathway was piloted between May 2023 and October 2024 without additional staffing resources. The duration of the pilot was determined by number of eligible patients and available staffing resources. Operational and clinical data were entered into the Research Electronic Data Capture (REDCap) secure web platform [15] by a project team member weekly.

Participants

All patients >18 years with a new traumatic-SCI admitted between May 2023-January 2024 were eligible. Patients were excluded if they had a pacemaker, were pregnant or breastfeeding, in ICU or had a concurrent severe acquired brain injury (post-traumatic amnesia duration >7 days). Eligible patients were approached and gave verbal consent to receive clinical care, as per the care pathway. Twenty-one participants undertook individualised rehabilitation as per Clinical Practice Guidelines [16] and 30–60-min of exercise training (supported by an EP) 2–3 days per week including weights and/or wheelchair skills except for 3 patients who were also participants in an intensive rehabilitation trial. All patients received the diet prescribed by their treating dietitian. BIS measurements were scheduled on patient rehabilitation timetables. Individualised body composition feedback to patients was integrated into face-to-face dietitian reviews or goal setting and healthy lifestyle counselling delivered by the dietitian and/or EP.

Six clinicians (5 dietitians and 1 exercise physiologist) who delivered care according to the care pathway between May 2023 and October 2024 were eligible and participated in the study.

Patient demographic and clinical and body composition data

Participant demographics, clinical characteristics and admission American Spinal Injury Association (ASIA) Impairment Scale (AIS) criteria [17] were collected prospectively from the electronic medical record (EMR). Weight and supine length were obtained as described previously [7].

Body composition measurements were taken, either before scheduled exercise physiology sessions or in the morning whilst participants were in bed, using a four terminal BIS instrument (SFB7, ImpediMed. Brisbane, Australia) whilst the patient was supine as previously described [7]. The BIS instrument was set to selected frequency mode and a single whole-body measurement was taken on the right side of the body at 50 kHz. Participants were advised to eat and drink as usual, empty bladder if voiding on sensation and avoid caffeine and exercise two hours before the measurement. Body composition (FFM and FM, percentage body fat) were calculated in REDCap using an SCI-specific equation FFM equation [18]. Individual energy requirements were also calculated in REDCap using a SCI-specific energy prediction equation [8] and injury and/or activity factors [19,20,21] deemed clinically appropriate by the dietitian. Data on nutritional goal setting and healthy diet counselling were gathered retrospectively from the EMR.

Staff demographic data

Demographic data on age, sex, occupation, duration of working with patients with SCI and previous experience using bioimpedance were collected via a staff survey in REDCap [15].

Adoption

The study lead collected data on the number of patients (i) admitted during the pilot study (ii) who were eligible, approached and consented to receive care and (iii) received care according to the care pathway.

Intervention delivery and adherence

Data collected included number and proportion of:

priority one patients (new enteral or parenteral nutrition, nil/negligible intake <25% for >5 days, specialised mealplan, high refeeding risk, significant loss of weight ≥ 10%) seen within 24 h;

priority two patients (predicted increased nutritional needs, ≤ 50% intake for >5 days, loss of weight 5–9.9%) seen within 48 h;

patients assessed and reviewed at all timepoints as per pathway timeframes;

patients who had assessments, reviews and clinical assessment measures performed as per the care pathway, including FFM and FM using BIS and energy requirements calculated using the SCI-specific Buchholz et al., [8] energy predication equation;

patients where percentage body fat guided a change in dietary management.

Adherence was classified as high (80–100%), moderate (50–79.9%) and low (<50%) [22].

Participant acceptability and appropriateness

Patient acceptability and appropriateness of the care pathway was assessed using semi-structured interviews in a subset of participants before discharge from rehabilitation. Patients were invited to participate in an interview with the study lead, gave verbal consent to participate and for audio recording of the interview. Sampling was purposive and aimed to recruit 10–15 patients of diverse age, sex and injury severity to gain a broad understanding of acceptability and appropriateness. The interview guide was composed of predetermined semi-structured questions and accompanied by follow-up probes and questions that emerged from the interview (Supplementary Table 2). Interviews were conducted in person with only the interviewer (study lead - trained in qualitative research methods) and participant present (one patient’s spouse was present) and lasted 10–33 min.

A focus group was conducted with clinicians who provided clinical care following the care pathway using a semi-structured interview guide in May 2024 (Supplementary Table 3). Clinicians provided written and verbal recorded consent for interview participation. The staff focus group was conducted, recorded and transcribed via Microsoft Teams and lasted 51 min. The interviewer had a pre-existing clinical relationship with most patients and a pre-existing professional relationship as a senior colleague with all clinicians.

The interview and focus group guide questions were developed based on the study aims, existing literature [1, 3, 4, 9,10,11, 23] and the key dimensions of acceptability [13, 24]. Each interview and the focus group were electronically audio recorded, de-identified (using numerical coding) by the study lead who conducted the interview; and transcribed verbatim using artificial intelligence software (Otter.au Los Altos, CA). The transcriptions were verified for accuracy against the audio recording by the study lead and corrected as required. All participants were offered the opportunity to check transcripts for accuracy.

Data management and analysisDemographic, clinical and operational data

After data entry into REDCap was completed, data were exported into Excel and/or Stata/BE 17.0 (College Station, TX) for analysis. Descriptive statistics including medians and interquartile ranges were used for continuous variables due to non-normal data distribution. Categorical variables and intervention delivery and adherence were reported as counts and proportions.

Patient interviews and staff focus groups

Interview and focus group transcripts were managed using NVivo 14.23.3 to facilitate thematic analysis [25]. Data collection and analysis for the patient interviews were completed simultaneously. Recruitment ceased when data saturation was reached. Five clinicians participated in the focus group. One researcher (KD) read and corrected interview and focus group transcripts in their entirety and completed initial open coding, which were reviewed by a second researcher (NK) after four interviews and at the completion of all interviews. Key concepts were identified from the data using an iterative and reflective process [25]. The two researchers then grouped the codes into themes.