Clinical assessments play a vital role in providing the information healthcare professionals need to better care for their patients. However, many of these clinical assessments include an evaluation of skin color, which may be leading to greater disparities in care.

Given that several clinical assessments in use today were developed using an entirely white patient population, they may not work well for patients with darker skin tones, which can result in inaccurate assessments, diagnostic errors, and worse outcomes.

Why Current Clinical Assessments Need Review

Two recent examples of assessment using skin color evaluation are Apgar Scores and Pressure Injury assessments.

• The Apgar Score is a clinical assessment tool for newborn babies that includes an evaluation of skin color. In England, the NHS Race and Health Observatory recommends [1] updating guidelines that use skin color for assessment and mentions using objective tools like bilirubinometers in conjunction with the Apgar score to provide a more complete picture.

• Healthcare providers use visual skin assessments to identify potential pressure injuries in their patients. However, the National Pressure Injury Advisory Panel [2] found that there are racial disparities in the development and healing of pressure injuries.

To create real change, we need to take a broader view that includes:

• Reviewing all clinical assessments to identify those that use skin color

• Understanding how healthcare providers are trained [3] (including what kinds of examples they’re given, how often the examples are limited to light-colored skin)

• Studying outcomes, by race, when a clinical assessment included evaluation of skin color

What You Can Do

1. Take action in your organization. Look at the clinical assessments in use in your facility – do they use skin color? Is there an objective measure that could replace the subjective evaluation of skin color? Are you looking at patient outcomes by race for care associated with the clinical assessments you identify?

2. Measure over time. How often are these assessments used? If there are more objective options, are your providers using them consistently (like bilirubinometry)? Do you see changes in outcomes by race after making changes to your assessments? 

3. Let us know what you learn. A clinical assessment tool using skin color without adequate resources for darker skin tones or additional objective measurements could be considered an unsafe condition. If you learn something that you think other facilities should know during your evaluation of your facility’s clinical assessments, the implementation of changes, or the tracking of patient outcomes, submit a Patient Safety Report, and let us know about it.

Interested in learning more about this topic? Check out additional resources below: 

• Newborn Health Checks Are Unreliable for Black and Asian Babies, Review Finds

• Current Perspectives on Pressure Injuries in Persons with Dark Skin Tones from the National Pressure Injury Advisory Panel

Citations

[1] Wise, Jacqui. 2023. “Newborn Health Checks Are Unreliable for Black and Asian Babies, Review Finds.” BMJ 382 (July): p1620. https://www.bmj.com/content/382/bmj.p1620

[2] Black, Joyce, Jill Cox, Virginia Capasso, Donna Z. Bliss, Barbara Delmore, Vignesh Iyer, Jacqueline Massaro, Cassendra Munro, Joyce Pittman, and Elizabeth A. Ayello. 2023. “Current Perspectives on Pressure Injuries in Persons with Dark Skin Tones from the National Pressure Injury Advisory Panel.” Advances in Skin & Wound Care 36 (9): 470.

[3] Pusey-Reid, Eleonor, Lisa Quinn, Mary E. Samost, and Patricia A. Reidy. 2023. “Skin Assessment in Patients with Dark Skin Tone.” American Journal of Nursing 123 (3): 36–43. https://www.mghpcs.org/MunnCenter/Documents/weekly/apr-23/Skin-Assessment-in-Patients-with-Dark-Skin-Tone.pdf