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Identifying Disparities in Sepsis Diagnosis for Unbiased Care

Contagion, Contagion, December 2021 (Vol. 06, No. 6),

Risk of inaccuracy with pulse oximeters and clinician knowledge gaps in people of color may affect sepsis evaluations and impact treatment plans.

According to the World Health Organization, approximately 49 million cases of sepsis are reported globally, resulting in nearly 11 million deaths per year.1 For those who do survive the initial infection, only half will make a full recovery, and the other half will die from resulting complications and disabilities. As new studies continue to highlight the importance of proper sepsis care, it’s critical that clinicians have access to the most up-to-date information. The COVID-19 pandemic has only magnified the importance of having reliable resources for clinicians, especially since COVID-19 and sepsis care can overlap. When care teams have access to the best clinical tools and updated studies, they know when and where to allocate resources during a crisis and can collectively work toward delivering the best, impartial care to all patients.

Patients with sepsis are often treated with supplementary oxygen and closely monitored to track sepsis progression, which can be fatal if not caught early. COVID-19 has increased the use of certain measures like pulse oximetry, which measures oxygen in the blood; however, in February, the FDA issued a warning about the limitations and risk of inaccuracy with pulse oximeters in patients of color.2 In addition, 2 articles recently revealed a substantial knowledge gap that may affect sepsis evaluation in Black patients or people with dark skin tone, which could impact subsequent treatment plans.

The New England Journal of Medicine (NEJM) published a study that found patients who identified as Black had nearly 3 times the frequency of occult hypoxemia (abnormally low oxygen concentration in the blood) that was not detected by pulse oximetry.3 Another study published in JAMA Network Open examined the impact that race can have on the accuracy of the Sequential Organ Failure Assessment (SOFA) score for in-hospital mortality.4 According to the study, the SOFA score overestimated mortality in Black patients compared with White patients, which in times of crisis could result in allocation of resources that favor White patients.

Both studies point to a need to be more discerning of the measures we’re currently using to identify and diagnose sepsis and to understand racial disparities in the assessments used for sepsis diagnosis. These disparities can potentially result in life-threatening impacts when patients should be escalated to intensive care but are improperly diagnosed by frontline care teams.

Identifying Racial Disparities in Sepsis: New Research

The findings in the study published in NEJM are incredibly important because pulse oximetry is a critical tool for the early evaluation of sepsis and can influence treatment plans. For example, low or borderline pulse oximetry results may prompt theclinician to perform an arterial blood gas (ABG) test, which is a more accurate way to measure oxygenation. With a discrepancy in detecting low readings for Black patients, the clinician may be misled into thinking that the patient’s oxygen level is acceptable and does not require an ABG.

The findings published in the JAMA Network Open article are also a cause for concern. If Black patients receive a higher SOFA score than White patients, they are deemed to have a higher mortality rate and less likely to survive sepsis. This information is incredibly important in times of crisis when the SOFA scores may potentially be used to dictate the allocation of health care resources during the activation of crisis standards of care (CSC).

During the COVID-19 pandemic, medical resources were in short supply, and some intensive care units needed to activate CSC to decide how to allocate medical equipment and resources to maximize patient care. When CSC is activated, this means that health care resources are directed to patients more likely to survive (eg, those with sepsis who have a lower SOFA score).

Both studies suggest potential for Black patients with sepsis to not receive the same level of care and life-saving resources needed to manage sepsis or other critical conditions. Clinicians need to have the educational tools and latest clinical guidance available that allow them to account for the difference in results between Black and White patients to prevent the often-unintentional disproportionate allocation of medical resources and equipment to White patients.

Although hypothetical, it may be deduced that if sepsis is not being identified and treated as diligently in Black or dark skin–toned patients, antibiotic therapy may be delayed and not administered until the patient is clinically sicker, which further compounds the undertreatment of sepsis in Black patients.

Closing Clinical Knowledge Gaps Through Education

Inequitable care has come under scrutiny recently and has highlighted the need for better ways to assess patients of different skin colors as well as the need for additional clinician education. The COVID-19 pandemic exemplified the need for up-to-date data, which can affect decision-making during CSC activation.

It is essential that hospitals facilitate open discussion to help foster awareness among physicians and health care workers about the overreliance on oximetry and underuse of the SOFA score for clinical decision-making. Care teams need to be armed with knowledge and awareness of how health care has left gaps and health disparities for Black patients, especially for life-threatening infections like sepsis. By combining access to updated studies and resources and proactively educating care teams to identify areas of unconscious bias in health care, hospitals can get one step closer to providing all patients equal care, regardless of skin color.

References

  1. WHO calls for global action on sepsis – cause of 1 in 5 deaths worldwide. News release. World Health Organization. September 8, 2020. Accessed November 2, 2021. https://www.who.int/news/item/08-09-2020-who-calls-for-global-action-on-sepsis---cause-of-1-in-5-deaths-worldwide
  2. Pulse oximeter accuracy and limitations: FDA safety communication. FDA. February 19, 2021. Accessed November 2, 2021. https://www.fda.gov/medical-devices/safety-communications/pulse-oximeter-accuracy-and-limitations-fda-safety-communication
  3. Sjoding MW, Dickson RP, Iwashyna TJ, Gay SE, Valley TS. Racial bias in pulse oximetry measurement. N Engl J Med. 2020;383(25):2477-2478. doi:10.1056/NEJMc2029240
  4. Miller WD, Han X, Peek ME, Charan Ashana D, Parker WF. Accuracy of the sequential organ failure assessment score for in-hospital mortality by race and relevance to crisis standards of care. JAMA Netw Open. 2021;4(6):e2113891. doi:10.1001/jamanetworkopen.2021.13891