Marga Hoogendoorn

136 ICU nurses not only in emergency situations like the COVID-19 pandemic, but also to cope with the daily scarcity of operational ICU-beds. Further research should include the impact of the supervising role of ICU nurses in workload instruments. We also recommend a further analysis of the optimal NAS per nurse. Whereas the developers of the NAS defined a total Nursing Activities Score of 100 points equal to the time spend by one Full Time Equivalent (FTE) nurse per shift, our research shows an optimum not exceeding 80 NAS points per nurse. The Dutch Guidelines for Intensive Care mention a maximum number of patients per nurse, but there is no strong evidence available for this number of patients per nurse. In case of a revision of the Dutch Guidelines of Intensive Care we advise a focus on the workload per nurse instead of the number of patients per nurse. When using the NAS to measure nursing workload and planning of nursing staff it is also important to compare the situation of individual hospitals with other hospitals. This gives ICU management feedback on several important factors such as nursing workload, the number of nurses per patient, the severity of patient illness, bed occupancy and patient outcome to keep on track in continuous quality assessment. Start working with the workload per nurse by using NAS also gives a good opportunity for national research and further validation of the optimal NAS per nurse ratio and development of a recalibrated and adapted scoring system. This improves the application of NAS in daily practice of the nurse and in ICU-management. Participation in the NICE capacity registry is an accessible way to benchmark data about nursing workload. In this context it is important to make the registration of the NAS as easy and little time consuming as possible. Automated collection and extraction of (a main part of) NAS from the Electronic Patient Record is the most valid and optimal way to reduce the administrative burden for nurses. The incorporation of both medical information and nursing information like NAS can be used for the development of a management tool like a dashboard. This management tool can help ICU-management to identify opportunities for improvement of quality of patient care and organization of care like ICU length of stay or efficient nursing staffing. Following the major role that NICE has played in supplying data for national benchmarks, they may also be able to play a stimulating role to the vendors of Electronic Health Records (EHR) regarding automatic data collection and extraction and development of a dashboard. Their influence however is limited as hospitals are the clients of those EHR vendors and not the NICE foundation. Finally, further research on the impact of deployment of other non-certified ICU nurses in the ICU on nursing workload is necessary. The COVID-pandemic has learned that this