The purpose of this study was to assess Richmond Agitation Sedation Scale (RASS) goal implementation in mechanically ventilated patients sedated in the emergency department (ED), compliance with RASS, and goal achievement. This study was a retrospective chart review at a large Level I trauma academic medical center. Patients who were intubated in the ED or en route to the ED between October 1, 2013, and October 1, 2014, were eligible for inclusion if they met the following criteria: aged 18 years or older, 24 hr or more on mechanically ventilated support receiving continuous sedation and/or analgesia during the first 48 hr of admission, and a hospital stay of 6 days or more. There were 205 patients identified; 104 failed inclusion, 101 were enrolled, and 62 were excluded. Thirty-nine patients (94.9%) had an RASS goal implemented in the ED, of which 37 patients (81.1%) had an RASS goal set by an ED physician. Assessment of the RASS was found to be inconsistent, as 56.8% of patients were evaluated by an ED nurse within 1 hr of sedative initiation. Of the 37 patients who had an RASS goal in the ED, 18.9% achieved their goal in the ED. A review of sedation prescribing revealed that 39% received a regimen of varied combinations of continuous infusions of propofol, dexmedetomidine, and midazolam throughout admission, 33% received a regimen of 2 of the aforementioned drugs, and 28% received only propofol. Median extubation time was 129 hr. Seven patients expired within 180 days of admission. The assessment of the RASS was a common practice, but there were inconsistencies in measurement. A limited number of patients achieved their RASS goal in the ED. These results support a provider and nursing knowledge deficit regarding RASS goal setting, proper documentation of RASS measurement, and the need for appropriate assessments.

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Pharmacists are often involved in creating, implementing, and evaluating initiatives that aim to improve medication use. Pharmacy initiatives can occur in various settings, can involve interactions with patients or prescribers to optimize medication use, and incorporate information from multiple sources. Similar to pharmacy initiatives, public health initiatives are heterogeneous, complex, and work with the public to improve health behaviors in a variety of settings. Various program planning and health behavior change techniques are utilized in the planning of public health programs. Community-based public health programs designed using social and behavioral theories have shown improved outcomes when compared with programs not based on theory. Given the overlapping objectives for planning community-based public health programs and pharmacy initiatives, the use of social and behavioral theories may provide pharmacists with an additional tool to assist in creation of multilayered, effective pharmacy initiatives. Data supporting two health behavior theories focused on individuals (Transtheoretical Model and Health Belief Model), and one ecological model (Social Ecological Model) are reviewed and applied to three different pharmacy initiative scenarios. Greater incorporation of behavioral change theories and models may be helpful in creating effective, comprehensive pharmacy initiatives.

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INTRODUCTION:The COVID-19 pandemic has led to devastating outcomes, especially among patients who progress to Acute Respiratory Distress Syndrome (ARDS). Corticosteroids improve survival and ventilator-free days in hospitalized patients with COVID-19 pneumonia requiring supplemental oxygen therapy. Though currently dexamethasone (DEX) is a first line corticosteroid due to its longer half-life and relative lack of mineralocorticoid activity, it is unclear whether alternate corticosteroids can demonstrate similar benefit. Historically, methylprednisolone (MP) has been the default treatment for pre-COVID ARDS and has shown benefit in severe Community Acquired Pneumonia due to its' high lung tissue penetration. Given increasing incidence of ARDS observed in severe COVID pneumonia, the goal of our study is to compare efficacy of MP vs DEX in moderate to severe ARDS. METHODS:This is a single center, multi-location, retrospective, observational study of 575 adult patients admitted to OSF Hospitals between 02/01/2020 and 03/31/2021 for treatment of confirmed COVID-19 pneumonia and moderate to severe ARDS defined as PaO2:FiO2< 200. Patients were grouped based on steroid regimen into one of three treatment arms: those receiving at least 6 mg of DEX (N=360) or 30 mg of MP (N=136) as single or divided daily dose, or sequential use of both DEX+MP (N=79). Demographic data, symptoms, laboratory values, steroid dosing and clinical outcomes were collected. RESULTS:The three treatment groups were similar in terms of baseline CRP, SAPS scores and procalcitonin levels. There was no difference in 28-day all-cause mortality rate among the three groups. The DEX+MP group demonstrated higher in-hospital mortality rate compared to either DEX or MP alone (60.8% vs 41.7% and 44.1%, respectively, p=0.008). The DEX+MP combination group had longer duration of stay compared to DEX or MP alone (21 days vs 12 and 13 days, respectively, p< 0.001) and spent more days in the ICU (14 days vs 6.5 and 7 days, respectively, p< 0.001). CONCLUSIONS:We did not observe 28-day mortality lowering effect across any of the three treatment groups. Dexamethasone was associated with reduced ICU and total hospital length of stay. A prospective, randomized trial comparing DEX and MP is warranted to further investigate potential superiority.