Marga Hoogendoorn

118 D I SCUSS I ON Our results showed that the increasing demand for nursing care during the COVID- period was recognizable in both a higher number of patients per nurse and a higher mean Nursing Activities Score per nurse, compared to the same months in 2019. Although the number of new admissions on the ICU was lower, the Nursing Activities Score per nurse and the number of patients per nurse were higher. The increase of the Nursing Activities Score per nurse was also disproportionate higher compared to the increase of the number of patients per nurse. This can be explained by the higher Nursing Activities Score per patient but also by the long length of stay of COVID-19 ICU patients. The continuous influx of COVID-19 patients in combination with a long length of stay and therefore a delayed outflow contributed to a high pressure on ICU beds. This pressure on the ICU beds resulted in cancellation of many planned post-operative patients, e.g. cardiac surgery patients. This is visible in the baseline characteristics; the total number of admissions in the COVID-period was lower compared to the non-COVID period, with also a lower number of planned surgical patients. The percentage of unplanned surgical patients compared to the total ICU population in the COVID-19 period was higher compared to the non-COVID period. Earlier research showed that the nursing workload of unplanned (medical and surgical) admissions is higher compared to planned (surgical) admissions 23 . During the COVID-19 period the percentage of patients with an unplanned admission, both medical and surgical, was increased. Comparing the baseline characteristics of the patients in our study with the baseline characteristics of all hospitals in the NICE database we must consider that there is a difference in the distribution of medical and elective or urgent surgical patients between the groups. However, the mean workload of the non-COVID patients during this period was not increased in our study, probably because the percentage of urgent admissions was still relatively low. Also the APS-score of the COVID-19 patients was higher in our study compared to the COVID-19 patients in all other hospitals. There is no unambiguous explanation for this difference. It is possible that the higher APS-score had an effect on the nursing workload, but the nursing workload is impacted by more aspects than the severity of illness 24 . Although the number of patients per nurse and the Nursing Activities Score per nurse were both increased during the COVID-period, this should be interpreted with caution. To expand the nursing staff also in the Netherlands non-ICU nursing staff was deployed on the ICU during the COVID-19 period. The ICU nurses were supported in the daily care for the ICU patients by e.g., general nurses or anesthesia nurses. They supported in basic