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2021 Poster Presentations

P21 - Let Us ROX Your Socks Off!: Using the ROX Index as an Early Identifier for Intubation


During the COVID-19 pandemic, medical-surgical nurses at a small rural community hospital accepted the challenge to care for more acutely ill patients. During the initial wave of the COVID-19 pandemic, patients were intubated; however, during the second wave, the decision was made to utilize high-flow nasal oxygen therapy (HFNO) when appropriate and maintain patients outside of critical care units. The institution had already created a tool to identify patients at high risk for requiring critical care that was completed daily. The clinical nurse specialist for the institution recognized the need to provide an objective measure for medical-surgical nurses to identify declining COVID-19 patients on HFNO. A literature search was performed, and the evidence-based tool the ROX Index for Intubation was implemented (Suliman et al., 2021). The ROX index predicts the likelihood that a patient will require intubation (Mellado-Artigas et al., 2021). The authors hypothesized that using the ROX index would assist with the early identification of those patients requiring intubation.

The clinical nurse specialist received approval to institute its use and began education. Nurses and respiratory therapists downloaded a free application that calculated the ROX score for the clinician. The score was then communicated with the hospitalist and pulmonologist. Patients initially placed on HFNO's ROX score was calculated at 2, 6, and then 12 hours for the duration of their stay unless there was a change in condition. If the patient’s condition changed or the settings on the HFNO were adjusted, the ROX was again performed at 2 and 6 hours before being performed every 12 hours.

Patients admitted from September 2021 to December 2021 were included in this retrospective review. The sample included 80 patients on HFNO, with only 8% requiring intubation. The ROX score was 90% effective in identifying those that required intubation, allowing for the intubation to be performed in a controlled setting before transferring the patient to critical care.

The ROX score was a valuable tool to ensure patients received appropriate care during the COVID-19 pandemic and empowered the medical-surgical nurse to have an objective measure of patient decline. Additionally, the ROX application was free to download; therefore, it was a fiscally responsible intervention to ensure patient safety. This project could easily be replicated in any medical-surgical unit caring for patients on HNFO. Limitations to the study include a retrospective review; unknown compliance rates for ROX use, as it is not built into the electronic medical record; and the impact of experimental treatments during the second wave.

•    Mellado-Artigas, R., Mujica, L. E., Ruiz, M. L., Ferreyro, B. L., Angriman, F., Arruti, E., Torres, A., Barbeta, E., Villar, J., & Ferrando, C. (2021). Predictors of failure with high-flow nasal oxygen therapy in COVID-19 patients with acute respiratory failure: a multicenter observational study. Journal of Intensive Care, 9(1), 1–9. https://doi.org/10.1186/s40560-021-00538-8
•    Suliman, L. A., Abdelgawad, T. T., Farrag, N. S., & Abdelwahab, H. W. (2021). Validity of ROX index in prediction of risk of intubation in patients with COVID-19 pneumonia. Advances in Respiratory Medicine, 89(1), 1–7. https://doiorg.lopes.idm.oclc.org/10.5603/ARM.a2020.0176


  • Cristen Mackwell, MSN, RN, CMSRN, NPD-BC, Clinical Specialist, Hackettstown Medical Center

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