Journal of Modern Medical

Introduction
Due to the wide range of services they provide, intensive care units (ICUs) can be considered as a small hospital within a large hospital that provides life-saving care for patients with critical conditions. The ICU is known as the bottleneck of performance control in the hospital, where compliance with standards is very important. Development and application of standards in ICUs leads to more patient survival and cost savings, because it prevents mistakes in the management of the unit and reduces preventable deaths. During the COVID-19 pandemic, due to the increase in the need for hospital beds and the insufficient capacity of the infectious disease department, it is inevitable to use all the capacity of the treatment staff and beds in other departments of the hospital. This may have an effect on the quality of care for the patient due to the nature of the department and being unspecialized to provide services during crisis. Therefore, when the ICU is dedicated to the care of infectious patients such as those with COVID-19, compliance with standards and protocols, especially in the field of infection prevention and control, becomes very important. In this regard and considering that limited studies have been carried out in Iran, the present study aims to examine the level of adherence to standards in the ICUs of hospitals affiliated to Mazandaran University of Medical Sciences during the COVID-19 pandemic.
Methods
This is a descriptive analytical study with a cross-sectional design that was conducted in 2021. The study samples were 19 ICUs of 19 hospitals affiliated to Mazandaran University of Medical Sciences who were selected by a census method. The data collection tool was a researcher-made questionnaire for evaluation of the ICUs. This questionnaire had 147 items and 8 dimensions of manpower (13 items), space and facilities (17 items), medical equipment (16 items), functioning (22 items), nursing processes (23 items), safety (22 items), management and leadership (10 items), and infection control (24 items) in ICUs. The items rated on a 5-point Likert scale. The total score was obtained by the sum of the average scores of all dimensions. Face validity and content validity of the questionnaire were confirmed based on the experts’ opinion. Then, its construct validity using factor analysis as well as its internal consistency were determined. The results showed that the factor load was more than 0.5 for all items and the average variance extracted was 0.81. Cronbach’s alpha value was 0.82 and composite reliability was 0.91, which were acceptable. To analyze the collected data, descriptive statistics (frequency, mean, percentage, standard deviation) and non-parametric tests of Wilcoxon, Friedman and Kruskal-Wallis were used in SPSS software, version 21 and Splus applications.
Results
The level of compliance with the standards in the ICU was 82.4% with mean score of 4.12±0.35 out of 5 points, which was favorable. The highest score was related to the dimension of “management and leadership (4.74±0.93) with a rate of 94.7%, followed by medical equipment (4.53±0.52), nursing processes (4.53±0.66), space, structure and facilities (4.47±0.39), safety (4.3±0.69), functioning (4.0±11.04) and manpower (4.19±0.42). The lowest score was related to the dimension of “infection control (3.42±1.24) with a rate of 68.4%. This difference in ranks observed in different areas was significant according to the results of Friedman test (p<0.05). According to the Wilcoxon test results, the total score of compliance with the standards was higher than the average standard score of 3 (p<0.05). The average scores obtained in all dimensions, except for the “infection control” dimension, were also higher than 3 (p< 0.05). The total score of compliance with the standards in the ICUs of teaching hospitals (4.35±0.31) was higher than in the ICUs of medical hospitals (4.04±0.33), but this difference was not significant according to the results of Mann-Whitney U test. In terms of dimensions, the differences were not significant, either (p>0.05).
Discussion
The study showed that, in overall, the ICUs of the study hospitals had a good compliance with the standards during the COVID-19 pandemic. The performance of the ICUs in the areas of management and leadership, medical equipment, and nursing processes was favorable, but it was lower in the field of infection control. To improve the conditions of ICUs as much as possible, the hospitals can share their experiences with each other by holding joint conferences and group visits of successful hospitals. In addition, training and planning for the optimal use of existing facilities and recording the measures taken can help improve compliance. In many cases, the hospitals that did not get a good score in some areas had not recorded their measures. Hospitals can improve the quality of their services by recording their measures using the software.

Ethical Considerations
Compliance with ethical guidelines
This study has ethical approval number IR.MAZUMS..REC.1399.8974 from Mazandaran University of Medical Sciences.

Funding
This article was done with the financial support of Mazandaran University of Medical Sciences.

Authors' contributions
Designing the framework of the study and responsibility for guiding and conducting the study and editing the article: Roya Malekzadeh; Designing the stages of study and final editing: Touraj Assadi; Findings and data analysis: Elahe Mahmoudi; Coordination for the visit of the specialized team to the hospitals: Fatemeh Montazeriun; Data collection: Touraj Assadi and Fatemeh Montazeriun.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
This article is the result of the research project of Mazandaran University of Medical Sciences. Therefore, the authors are grateful for the cooperation of the research and treatment departments of this university


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