Spreading the Veterans Health Administration's emergency department rapid access clinics (ED-RAC) innovation: Role of champions and local contexts.

BACKGROUND: Champions frequently facilitate change in healthcare, but the literature lacks specificity regarding champion activities and interactions with local contexts. The Veterans' Health Administration (VA) Emergency Department (ED) Rapid Access Clinic (ED-RAC) initiative used champions to spread an innovation aimed at achieving timely specialty follow-up care for ED patients. We assessed the roles champions and local contexts played in successful ED-RAC spread in the initiative's first year. METHODS: Our mixed method formative evaluation included serial questionnaires, fieldnotes from meetings, and champion interviews. We analyzed qualitative data from spread site rapid and non-rapid implementers, assessing champion and contextual factors. RESULTS: Among 24 participating VA sites, 11 were rapid implementers (i.e., implemented ED-RAC in first year), 13 were not. Site champions at rapid sites described crossing multiple organizational units to get tasks accomplished (e.g., gaining buy-in, requesting resources); champions at non-rapid sites experienced inter-departmental communication challenges and competing demands. Champions at rapid and non-rapid sites encountered similar context-related barriers (e.g. scheduling complexities) and facilitators (e.g. enthusiastic buy-in), but differed in leadership and resource barriers. CONCLUSIONS: Identifying site champions was not enough to assure rapid innovation spread. Interdependencies between ED-RAC implementation requirements (e.g., boundary spanning, resources) and champion and contextual factors helped explain variations in progress. IMPLICATIONS: Tailoring spread support to champion and contextual factors may facilitate more rapid spread of innovations.

Concomitant presentation of carpal tunnel syndrome and trigger finger.

BACKGROUND: Carpal tunnel syndrome (CTS) and trigger finger (TF) are common conditions that may occur in the same patient. The etiology of most cases is unknown. The purpose of this study was to evaluate the rate of concomitant occurrence of these two conditions at presentation and to compare the concomitant occurrence in normal and diabetic patients. METHODS: One-hundred and eight consecutive subjects presenting to our hand clinic with CTS and/or TF were evaluated. The existence of both of these conditions was documented through a standard history and physical examination. The definition of trigger finger was determined by tenderness over the A1 pulley, catching, clicking or locking. CTS was defined in the presence of at least two of the following: numbness and tingling in a median nerve distribution, motor and sensory nerve loss (median nerve), a positive Tinel's or Phalen's test and positive electrophysiologic studies. RESULTS: The average age of the participants was 62.2 +/- 13.6 years. Sixty-seven patients presented with symptoms and signs of CTS (62%), 41 (38%) subjects with signs and symptoms of TF. Following further evaluation, 66 patients (61%) had evidence of concomitant CTS and TF. Fifty-seven patients (53% of all study patients) had diabetes. The rate of subjects with diabetes was similar among the groups (p = 0.8, Chi-square test). CONCLUSION: CTS and TF commonly occur together at presentation though the symptoms of one condition will be more prominent. Our results support a common local mechanism that may be unrelated to the presence of diabetes. We recommend evaluation for both conditions at the time of presentation.