Racial Equity in Sepsis Care Matters

As Black History Month draws to a close, two of our Advisory Board members, Dr. Selena Gilles, DNP, ANP-BC, CNEcl, CCRN, and Dr. Sandy Cayo, DNP, FNP-BC, APRN, reflect on the need for greater racial equity in sepsis care and take a close look at sepsis awareness, incidence, and outcomes in the Black community.  

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Over the last year, we have been plagued by the public health crisis of the COVID-19 pandemic. At the same time, we continue to face the public health crises of social injustice and systemic racism. COVID has thrown into sharp relief the long-existing health disparities closely linked with social, economic, and environmental disadvantages—and, as COVID-19 is an on-ramp to sepsis, it has highlighted stark sepsis-related disparities in turn. Year after year, and especially in 2020, we’ve continued to see overwhelming differences in sepsis-related outcomes, morbidity, and mortality in communities of color.

Sepsis is one of the most common causes of inpatient mortality, affecting almost 2 million patients annually and contributing to almost 300,000 deaths each year[i]. Communities of color experience a disproportionate burden of this sepsis-related suffering, and particularly Black communities: unfortunately, research has shown that despite standardization of care, a wide variability in mortality rates remain, with minority populations having increased incidence, hospitalizations, and complications when compared to white populations.

These are the facts:

• American Indians and Alaskan Natives in the Indian Health Service area are 1.6 times more likely to die from sepsis than the national average[ii];
• Asian and Pacific Islander patients are 18% more likely to die from sepsis than white patients[iii];
• Black or Hispanic children with severe sepsis or septic shock are approximately 25% more likely to die than non-Hispanic white children[iv];
• Black and Hispanic patients have a higher incidence of severe sepsis as compared to white patients (1.7 times the rate for Blacks, and 1.1 times the rate for Hispanics)[v];
• Black children are 30% more likely than white children to develop sepsis after surgery[vi];
• Black women have more than twice the risk of severe maternal sepsis as compared to white women[vii].

These disparities are systematic, avoidable, and unjust.

In light of such alarming statistics, equitable, timely sepsis care, education, and support for at-risk and underserved communities is important now more than ever. As the leading sepsis organization in the United States, Sepsis Alliance aims to reduce harm caused by sepsis and help eliminate preventable disparities in sepsis incidence, morbidity, and mortality. That’s why we’ve dived headfirst into sepsis equity work in recent months.

This Black History Month, Sepsis Alliance recognizes not only the need to celebrate the amazing contributions of Black individuals, but also to recommit to addressing barriers and improving sepsis outcomes for African American patients specifically. We know, for example, that sepsis awareness is significantly lower for Black individuals (49%) than for white individuals (76%)[viii]—and still, Black patients bear nearly twice the number of sepsis deaths, relative to the size of the Black population, as compared to whites (80%-92% higher)[ix].

We recognize challenges and barriers related to implicit bias, structural racism, and medical mistrust: structural racism has been determined as a risk factor contributing to disparities in healthcare; implicit or unconscious bias is the association of negative attributes with individuals based on irrelevant characteristics such as race or gender. Each plays a role in patient outcomes, morbidity, and mortality, especially for disproportionately-affected Black patients.

Among Sepsis Alliance’s goals for combatting these problems are to increase the collection, stratification, and use of race, ethnicity, language preference, and other sociodemographic data to improve quality and safety related to sepsis. We hope to increase cultural competency training for providers, to ensure culturally responsive care around sepsis. We will work to target outreach to caregivers, patients, survivors, and families located in underserved communities, to expand education and improve the health of all communities. And we aim to advance diversity in our own leadership and governance, to better reflect the communities we serve.

We must eliminate disparities based on social determinants of health—like race or ethnic group, socioeconomic status, gender, age, sexual orientation, or gender identity—which adversely affect groups of people who have historically experienced discrimination and exclusion, including Black and African American patients in the health system. Achieving health equity and dismantling health disparities require valuing everyone equally; our focuses must not only be on deep-rooted historical and contemporary injustices, but also on education, support, and investment in at-risk and underserved communities.

 

[i] Hall M.J., Levant S., DeFrances C.J. Trends in Inpatient Hospital Deaths: National Hospital Discharge Survey, 2000–2010. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; Washington, DC, USA: 2013. pp. 1–8.

Rhee C., Dantes R., Epstein L., Murphy D.J., Seymour C.W., Iwashyna T.J., Kadri S.S., Angus D.C., Danner R.L., Fiore A.E., et al. Incidence and trends of sepsis in us hospitals using clinical vs claims data, 2009–2014. JAMA. 2017;318:1241–1249. doi: 10.1001/jama.2017.13836.

Singer M., Deutschman C.S., Seymour C.W., Shankar-Hari M., Annane D., Bauer M., Bellomo R., Bernard G.R., Chiche J.-D., Coopersmith C.M., et al. The third international consensus definitions for sepsis and septic shock (sepsis-3) JAMA. 2016;315:801–810. doi: 10.1001/jama.2016.0287.

[ii] Disparities. (2019, October) https://www.ihs.gov/newsroom/factsheets/disparities/.

[iii] Jones, J. M., Fingar, K. R., Miller, M. A., Coffey, R., Barrett, M., Flottemesch, T., Heslin, K. C., Gray, D. T. and Moy, E. (2017) Racial Disparities in Sepsis-Related In-Hospital Mortality: Using a Broad Case Capture Method and Multivariate Controls for Clinical and Hospital Variables, 2004-2013, Critical Care Medicine, 45(12), e1209-e1217.

[iv] Thavamani, A., Umapathi, K. K., Dhanpalreddy, H., Khatana, J., Chotikanatis, K., Allareddy, V. and Roy, A. (2020) Epidemiology, Clinical and Microbiologic Profile and Risk Factors for Inpatient Mortality in Pediatric Severe Sepsis in the United States From 2003 to 2014: A Large Population Analysis, Pediatric Infectious Disease Journal, 39(9), 781-788.

[v] Barnato, A. E., Alexander, S. L., Linde-Zwirble, W. T. and Angus, D. C. (2008) Racial variation in the incidence, care, and outcomes of severe sepsis: analysis of population, patient, and hospital characteristics, American Journal of Respiratory and Critical Care Medicine, 177(3), 279-284.

[vi] Nafiu, O. O., Mpody, C., Kim, S. S., Uffman, J. C. and Tobias, J. D. (2020) Race, Postoperative Complications, and Death in Apparently Healthy Children, Pediatrics, 146(2).

[vii] Bauer, M. E., Bateman, B. T., Bauer, S. T., Shanks, A. M. and Mhyre, J. M. (2013) Maternal sepsis mortality and morbidity during hospitalization for delivery: temporal trends and independent associations for severe sepsis, Anesthesia & Analgesia, 117(4), 944-50.

[viii] Sepsis Alliance Awareness Survey. (2020) https://www.sepsis.org/2020-sepsisawareness-survey/ .

[ix] Kempker, J. A., Kramer, M. R., Waller, L. A. and Martin, G. S. (2018) Risk Factors for Septicemia Deaths and Disparities in a Longitudinal US Cohort, Open Forum Infectious Diseases, 5(12), ofy305.

Mayr, F. B., Yende, S., Linde-Zwirble, W. T., Peck-Palmer, O. M., Barnato, A. E., Weissfeld, L. A. and Angus, D. C. (2010) Infection rate and acute organ dysfunction risk as explanations for racial differences in severe sepsis, JAMA, 303(24), 2495-503.