As the deputy editor in critical care for UpToDate®, I survey all the relevant clinical journals to synthesize new evidence and edit our sepsis topics. In my review, two articles stood out as they pointed to a significant knowledge gap that may affect sepsis evaluation in Black patients or people with dark skin-tone, which, in turn could impact subsequent treatment.
One study that appeared as a correspondence in The New England Journal of Medicine (NEJM) found that compared with patients who self-identified as White, patients who self-identified as Black had nearly three times the frequency of occult hypoxemia (abnormally low oxygen concentration in the blood) that was not detected by pulse oximetry, a standard tool that is commonly used to evaluate patients who potentially have sepsis.
Another article from The Journal of the American Medical Association (JAMA) Network Open studied the impact of race on the accuracy of the Sequential Organ Failure Assessment (SOFA) score for in-hospital mortality. In this study, SOFA scores from a cohort of patients admitted to the emergency department overestimated mortality in Black compared with White patients.
Since our editorial team works to address issues regarding racial equity and highlight any differences in care between races, these two articles are highly relevant and timely.
Racial inequities: Impact on clinical effectiveness and patient care
The findings from the NEJM article that pulse oximetry is three times more likely to inaccurately measure oxygen levels in Black compared with White patients is highly clinically relevant.
Pulse oximetry, used to measure the percentage of oxygen saturation in the blood, is a standard tool used in the early evaluation of sepsis. When values are low or borderline (e.g., < 92%), this might prompt a bedside clinician to perform an arterial blood gas (ABG) test, which is a more accurate way to measure oxygenation. If the pulse oximetry in Black patients reads as normal, a clinician may be misled into thinking that the patient’s oxygen level is acceptable and not obtain an ABG, when in fact it may be much lower. In such cases, appropriate oxygen therapy may not be administered.
The study from JAMA Network Open describing overestimation of in-hospital mortality by the SOFA score in Black compared with White patients has implications for healthcare resource allocation, particularly in times of crisis. The SOFA score is a 10-point check system for determining organ function assessment in sepsis patients to predict mortality. The higher the SOFA score, the higher the mortality; meaning the patient is less likely to survive sepsis.
Under normal circumstances, the SOFA score has minimal implications for healthcare resources. However, during times of crisis, the SOFA score has the potential to be used to direct medical resource allocation, such as intensive care unit resources. During crises, such as the Covid-19 pandemic, existing healthcare resources can be overwhelmed, and Crisis Standards of Care (CSC) may need to be activated. CSC is designed to redirect healthcare resources towards patients who are more likely to survive. If the SOFA score does indeed overestimate the actual mortality from sepsis in Black patients, then this rationing of health care resources may not favor Black patients compared with White patients.
Advocating awareness to close clinical knowledge gaps
As a practicing physician at Tufts Medical Center and Lowell General Hospital, the issues surrounding inequity are openly discussed during conferences and rounds. Open discussion helps build awareness among physicians and healthcare workers of the over-reliance on oximetry and under-use of the SOFA score for clinical decision-making.
The Covid-19 pandemic highlighted the potential need for resource allocation and a different style of decision-making should the CSC be activated. Inequitable care has also come under scrutiny and highlights the need for better ways to assess patients of different skin color. Emphasizing the need to educate clinicians in this regard, the U.S. Food and Drug Administration issued a warning in early 2021 about the limitations and accuracy of pulse oximeters; thereby raising the profile and importance of the equitable provision of healthcare.
Within UpToDate, we have highlighted these issues in our topics. For example, we published both articles in our “What’s New” publication, which is sent to subscribing providers within a few weeks of the original publication. We also incorporate these issues into several relevant topics, sepsis as well as non-sepsis content and Covid-19 content.
In summary, neither the SOFA score nor pulse oximetry performs the same way in Black individuals as they do in White people, which puts Black individuals at a disadvantage from a healthcare perspective. Healthcare leaders and physicians need to be aware of the equity gaps so they can compensate for and work around them to minimize the gap. Both studies have helped to raise the profile of these inequities and will hopefully direct change to help improve the standard of care for Black patients with sepsis.