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.