Marga Hoogendoorn

119 care, but also in special procedures such as turning the patient into prone position and back or daily hygienic procedures. It is important to mention that the number of non- ICU nurses has not been included in the data in the NICE capacity registry and therefore not in our analysis because we did not have a data entry field for this kind of nurse. This should be considered when interpreting the results of the Nursing Activities Score per ICU nurse, especially in the month April 2020. The NAS was filled in by the ICU nurse but the time the non-ICU nurse spend at bedside is not mentioned in all the items of the NAS. If the non-ICU nurse support in the mobilization procedures it is incorporated in item 6b because the ICU nurse is performing the procedure with 2 nurses, but the dressing procedures of the non-ICU nurse are not incorporated. This should also be considered interpreting the number of patients per nurse. During the COVID-period the nurse took care for even up to 5 patients per nurse, but the nurse might be supported by a non-ICU nurse. Despite this support, the ICU nurse held the overall responsibility for the care of the patients. The supervision of a general or anesthesia nurse was a new aspect for an ICU nurse. This could mean that the ICU nurses were taking care for three or even more critically ill patients and were supervising a general or anesthesia nurse in the process of daily care. Although the support for the ICU nurses enlightened their task, the new coordinating role added to their responsibilities and therefore to their workload. Our second aim was to describe differences in nursing workload of COVID-19 patients versus pneumonia patients and differences in nursing workload of non-COVID and non-pneumonia patients admitted to the ICU. The results of our study clearly showed that COVID-19 patients cause a significantly higher ICU nursing workload compared to pneumonia patients in the non-COVID period. This confirms our expectation that the care for a COVID-19 patient requires more time from an ICU nurse than the care for a regular pneumonia patient. This higher workload was mainly due to nursing interventions like monitoring and titration with bedside observation, respiratory care, mobilization, hygienic procedures and taking care for the patient and his or her relatives. The increase in time for monitoring and titration with bedside observations is possibly related to the hygiene procedures. It is conceivable that the increase of the time that ICU nurses stayed at the bedside for observation, monitoring and titration was influenced by the time the nurses needed for complex dressing procedures for personal protection 7 . The ICU nurses perceived the complex dressing procedures as an aggravating factor in the workload and avoided extra dressing procedures by staying at the bedside. This could also be responsible for the increase in time needed for hygienic procedures. It should be noted that a substantial part of the COVID-19 patients is categorized in category 4a, although isolation is part of the definition of 4b. This can be explained by the use of cohort-isolation for COVID-patients in several hospitals. After entering the cohort-unit with the personal protection equipment the nurse could take care for the patients with the