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Component Gaps IdentifiedActivities & Actions PriorityObjectivesTools UsedMethodGuideline DisseminationTimelineResponsibilityLevelKPIsTarget (%)TotalCompletedProgress (%)Completion DateSustaining ImprovementsReward Compliance
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 General Directorate of Infection Prevention and Control in Healthcare Facilities (GDIPC)
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National VAE Reduction Strategy (VARS) Master Plan
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The NVARS Master Plan is Now Underway

The NVARS Master Plan, launched on February 2, 2025, marks the beginning of an ambitious and transformative journey. This initiative is already in motion, focusing on achieving key objectives, streamlining processes, and implementing strategic measures for long-term success.

As the plan progresses, we are seeing innovation drive change, resources being optimized, and stakeholders aligning towards shared goals. The commitment of our team and partners remains the driving force behind this initiative, ensuring that every step taken contributes to measurable and sustainable impact.

With a clear roadmap, defined milestones, and a relentless pursuit of excellence, we are actively shaping a more efficient and dynamic future. This is just the beginning—together, we will continue overcoming challenges, leveraging opportunities, and pushing the boundaries of what’s possible.
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Component Gaps IdentifiedActivities & Actions PriorityObjectivesTools UsedMethodGuideline DisseminationTimelineResponsibilityLevelKPIsTarget (%)TotalCompletedProgress (%)Completion DateSustaining ImprovementsReward Compliance
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Governance EngagementLack of Leadership Engagement & CommitmentIdentify specific areas where leadership involvement is lacking, such as policy support, resource allocation, or participation in infection prevention meetings.MediumTo pinpoint gaps in leadership involvement to ensure active participation in infection prevention efforts. Leadership involvement QuestionerA structured questionnaire was distributed to hospital's leaders thru Infection Control Directors to assess gaps in leadership involvement will be supervised by MOH cluster Coordinators. _9-16/2/2025MOH ClusterMOH ClusterSurvey Response Rate80%4090%_Appreciation and Acknowledgment email to Leaderships for response
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Infection Control Dep.Hospital
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Analyzing a Report for Leadership Involvement: Questionnaire FrameworkGDIPC Team will analyzed the data to identify areas for improvement._27/2/2025Surveillance TeamGDIPCPercentage of Analyzing reports of Leadership Involvement for 18 regions100%170%__
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GDIPC Meet the leaderships in all regions (Online with Leadership Teams and MOH Leaders across regions and key stakeholders from the Ministry of Health) and Regional team meet leaders in hospital level.CriticalTo enhance understanding of VAE prevention protocols and their impact on patient safety. Encourage compliance and leadership engagement in VAE prevention strategies.Strategy Tracking tool, Meeting attendance & Minutes.Online Launch Plan for VARS Strategy with Leadership Teams and MOH Leaders, involving leadership teams across regions and key stakeholders from the Ministry of Health (Representatives: Respiratory Therapy (RT), Pharmacy, Physiotherapy (PT), Adult ICU, PICU, NICU & Nursing).
Sending Invitation email thru GDIPC Directors.		_2/2/2025GDIPCGDIPCOnline Strategy launching 100%171694%_Recognizing Email to leaderships
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Online meetings or in-person support visits will be organized with leadership teams across all regions._2 monthsMOH BranchesMOH BranchesCompletion of required Meeting session within 2 months 100%4090%_Recognizing Email to leaderships
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Plan for Creating a Video to Introduce VAE Prevention StrategyLowA professional production team will handle video creation, ensuring high-quality visuals and clear messaging.
The video will be shared with all leadership in healthcare facilities and used as an awareness tool, also upload it in the website.		_1 monthSurveillance TeamGDIPCShare the video to 100% of 17 Regions via email & website.100%170%__
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Evaluating Leadership Engagement in Infection Prevention Efforts by cluster coordinators.
MediumTo ensure leadership visibly participate, well-informed and able to make decisions effectively, VAE (Ventilator-Associated Events) reports should be clear, focused, and actionable.Checklist for Evaluating Leadership Engagement in Infection Prevention Efforts1- Conduct semi-annual evaluations to ensure a comprehensive and unbiased assessment.
2- Analyze sampled documents to evaluate leadership participation, key discussion points, and decisions regarding infection prevention initiatives, with a focus on VAE prevention strategies.
3- Compile findings into a detailed report, providing constructive feedback to leadership by highlighting strengths and identifying areas for improvement to support better decision-making and increased engagement in VAE prevention efforts.
4- Share the findings and outcomes with GDIPC to ensure alignment and collaborative improvement.		_Semi-annualMOH ClusterMOH ClusterPercentage of conducted Checklist in 100% of Hospitals in each Cluster 100%8180%Regular Monitoring and Provide ongoing feedback to leadership teams on their progress and areas for improvement.Recognition Feedback email
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Absence of a clear definition and dissemination of staff roles and responsibilitiesDistributing the Roles and Responsibilities and disseminate Information by Using meetings, emails, posters, or handouts to communicate roles and responsibilities, ensuring everyone has access to the information.HighDefine and disseminate clear roles and responsibilities for staff involved in VAE protocol implementation.Digital posters and Documented roles and responsibilities shared with staff.1- Email Distribution: Share comprehensive guides and relevant guidelines directly with Infection Control Directors in all hospitals via email for immediate dissemination.
2- Digital Posters: Develop visually engaging and easy-to-understand digital posters to highlight key information effectively.
3- Website Upload: Upload all materials to the official website to ensure convenient and ongoing access.
4- Monitoring: Evaluate implementation and adherence to the distributed materials during validation visits to ensure effectiveness and compliance		VAEs Surveillance Guideline 1 monthSurveillance TeamGDIPCShare the roles and responsibilities documents to 100% all regions100%170%Randomly Monitoring and Provide ongoing feedback to leadership teams on their progress and areas for improvement._
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Ensure that hospitals develop and implement comprehensive policies outlining specific tasks and responsibilities for each specialty within the multidisciplinary team. These policies should promote collaboration, clarity, and accountability to enhance patient care outcomes.HighTo Standardize Clinical Practices and Improve Compliance with Protocols and simplify processes, ensuring that tasks are performed accurately and efficiently without unnecessary delays.official Communication Tool: Distribute emails with Directors of Infection Control department in hospitals use a digital posters for a quick guides.1 Week MOH BranchesMOH Branches Persentage of hospitals implemented the distrbuted guides100%4090%__
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The absence of regular multidisciplinary rounds can lead to fragmented care and missed opportunities for early detection and prevention of Ventilator-Associated Events (VAEs).Establishing a Structured Multidisciplinary Rounds and use a structured tool daily.Medium1- Promote collaboration among physicians, infection control staff, respiratory therapists, physical therapists, and nurses to ensure clear and consistent decision-making.
2- Maintain time-efficient rounds by ensuring discussions are concise and focused.
3- To guide infection control staff in addressing all critical tasks for preventing Ventilator-Associated Events (VAE) during daily multidisciplinary rounds.		Multidisciplinary Rounds Checklist Card for VAE Prevention
1- Design a Comprehensive Daily Checklist Card to guide infection Control Staff in VAE Prevention During Multidisciplinary Rounds_1 monthSurveillance TeamGDIPCCompletion of Multidisciplinary Rounds Checklist Card for VAE Prevention100%11100%
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2- Create a visually engaging training poster to familiarize the multidisciplinary team and distributed to all hospitals._1 MonthSurveillance TeamGDIPCCompletion of visually engaging training poster and distributed to all regions.100%10%
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Insufficient FeedbackUtilizing VAE Leadership Communication ToolHighUtilize metrics as effective tools to drive meaningful team discussions and foster collaboration. Leverage data to identify gaps, uncover root causes, and pinpoint areas for growth, ensuring an objective and data-driven approach to continuous improvement.Communication tool VAE Prevention Leadership Discussion FormCreate a VAE Prevention Leadership Discussion Form and ensure all relevant leadership (e.g., Hospital administration, infection control heads, ICU managers) receive the template._1 weekSurveillance TeamGDIPCCompletion of VAE Prevention Leadership Discussion Form and distributed officially to all regions100%10%Regular Monitoring and Provide ongoing feedback
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Require infection control departments to regularly process VAE Prevention Reports for all relevant stakeholders at the hospital level and ensure they are reviewed by Branches and Cluster Coordinators.Critical1- Ensure timely and consistent communication of VAE prevention performance to all relevant stakeholders.1- Use the official communication methods.
2- VAE Prevention Monthly Report.
3- Strategy Tracking tool		1- MOH branches will share with Infection Control Directors with a standardized VAE Prevention Report template._MonthlyInfection Control Dep.HospitalPercentage of VAE Prevention Report submissions by Infection Control Departments
100%409#DIV/0!Regular Monitoring and Provide ongoing feedbackAppreciation and Acknowledgment email to IC departments for response
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2- Ensure Infection Control Directors are regularly distribute VAE Prevention Reports to key stakeholders, including ICU Heads, Nursing staff, and Respiratory Therapists (RTs)._
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2- Monitoring & evaluate progress, identify gaps, and promote best practices for continuous improvement within clusters.MOH Branches quarterly report (HAIs Surveillance Report).3- Quarterly reviews at the MOH Branch level will be conducted to assess performance trends, evaluate the effectiveness of interventions, identify any compliance or outcome gaps, implement necessary actions, and report the findings in the HAIs Surveillance Report to the GDIPC._Every 3 months MOH BranchesMOH BranchesPercentage of VAE Prevention Reports analyzed by MOH branches within the required timeframe.100%180%
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Fear of blame can discourage healthcare staff from reporting of Ventilator-Associated Events (VAE)Promote the use of a recognition culture to motivate and engage staff.MediumEncourage and motivate staff to foster a culture of recognition and appreciation.Suggestion of Motivated activities.Ensure hospitals conduction some activities to motivate staff._Every 3 monthsHospital leadershipHospitalNumber of events or meetings held yearly to announce and celebrate the "VAE Prevention Champion.3, 100%30%Regular Monitoring and Provide ongoing feedbackAppreciation and Acknowledgment email to hospitals leaders & IC departments for conducting activities
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To foster a non-punitive reporting culture that encourages staff to openly report errors, near misses, and safety concerns, promoting continuous learning and improvement in patient care.Official Communication and Agreement Remind leaders to consistently emphasize during Strategy launching, or sending email and validation visits that event reporting is a tool for improvement, not punishment._OngoingGDIPCGDIPC_Randomly auditing and Provide feedback
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Surveillance ProgramData Collection Gaps in electronic system that can affect the quality and reliability of the findings.Optimize Power BI CapabilitiesHighTo implement or improve dashboard capabilities for monitoring and decision-making Communication with leen group with action planFormally submit the Requirements to LEEN Group with Time Frame and collaborate with them to prioritize the requirements based on urgency, impact, and feasibility._ImmediatelySurveillance Team/leenGDIPCPercentage of Requirements Achieved Within the Agreed-Upon Time Frame100%#DIV/0!Regular Monitoring and Provide ongoing feedback
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Incomplete documentation can hinder the accurate monitoring, prevention, and management of VAEs.Implementing Automated Ventilator-Associated Events (VAE) Identification through Integration of Daily VAE Monitoring.HighAutomating VAE identification can improve accuracy, efficiency, and timeliness in recognizing potential VAEs, ultimately leading to better patient outcomes and more effective infection control.1- Workflow for Daily Automated VAE Monitoring.
2- Daily Automated VAE Monitoring Sheet		Collaborating with Experts to Design a Daily Automated VAE Monitoring Sheet to develop a user-friendly, automated monitoring tool to track and analyze Ventilator-Associated Events (VAE) metrics daily, improving efficiency, accuracy, and patient safety._ImmediatelySurveillance TeamGDIPCComplete integration of automated VAE monitoring system within 2 months.100%#DIV/0!Randomly auditing and Provide feedback
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Develop and enforce a standardized documentation process for recording key information related to ventilator management and VAE care bundles.HighTo ensure accurate, consistent, and comprehensive documentation of ventilator management, and VAE care bundle compliance.VAE management Forms and Bundle care in (Adult, Pediatrics and Neonate)Develop and updating standardized forms templates, Distributed officially and upload it in WEBSITE and conduct regular training sessions to emphasize the importance of consistent documentation. Ensure staff are trained on accurately recording key information to maintain clarity and compliance._ImmediatelySurveillance TeamGDIPCPercentage of completion of all required documentations.100%#DIV/0!Annually reviewing VAE related forms by GDIPC team
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Conduct periodic training for staff on the importance of complete & accurate documentation.MediumImproved staff competence and adherence to documentation standards._Immediately MOH BranchesMOH BranchesPercentage of trained hospitals90%4090%Randomly auditing and Provide feedback
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Lack of a comprehensive line listing to capture required surveillance dataMaintain a comprehensive line listing organized.HighTo maintain a comprehensive and well-organized line listing that captures all required surveillance data points, enabling effective trend monitoring, gap identification, and compliance with surveillance standards.HAIs line-listing ExcelCreate or update a structured line listing template in excel with predefined fields to capture all required data points and distributed to all hospitals _ImmediatelySurveillance TeamGDIPCDistribute the line listing template to 100% of MOH Branches100%180%Randomly auditing and Provide feedback
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Lack of systematic VAE investigation and monthly feedback, missing opportunities for improvement.Promote the use of RCA for every identified VAE and implement CAPs for timely resolution. Provide monthly feedback to staff, highlighting findings and improvements. MediumEnsure the timely and effective resolution of Ventilator-Associated Events (VAEs).Use the official communication methods. HAIs Root Cause Analysis (RCA) and Corrective Action Plan TemplatesRedistribute HAIs Root Cause Analysis (RCA) template to all hospitals, upload it in WEBSITE and emphasize the importance of investigating each identified Ventilator-Associated Event (VAE). Provide staff training on RCA tools and methodologies to enhance their investigative skills._ImmediatelySurveillance TeamGDIPCDistribute HAIs Root Cause Analysis (RCA) and Corrective Action Plan Templates to 100% of regions100%180%Randomly auditing and Provide feedback
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Monitor progress and evaluate intervention effectiveness through follow-ups and trend analysis based on HAIs Escalating process.HighPromote continuous improvement and prevent recurrence.Monitoring the Progression of the Corrective Action Plan (CAP)._QuarterlySurveillance TeamGDIPCMonitor the closure of corrective action plans during the Red Zone (persistent high rates for over 3 months) and the Black Zone.100%#DIV/0!Randomly auditing and Provide feedback
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Lack of clear data collection processes, leading to inconsistencies in tracking and reporting.Develop and implement standardized data collection processes to ensure consistent, accurate, and reliable tracking and reporting. This includes providing clear guidelines, using uniform forms, and delivering structured training for all staff involved in data collection. ensure hospital sopLowTo establish clear and standardized data collection processes that ensure consistent, accurate, and reliable tracking and reporting for improved decision-making and outcomes.VAE management Forms and Bundle care in (Adult, pediatrics and Neonate) and Daily Automated VAE Monitoring SheetDevelop standardized documentation templates and conduct regular training sessions to emphasize the importance of consistent documentation. Ensure staff are trained on accurately recording key information to maintain clarity and compliance.Guidelines for VAE Data Collection Processes1 MonthSurveillance TeamGDIPCCompletion of flowchart for VAE Data Collection Processes and distribute it to all regions100%180%Randomly auditing and Provide feedback
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Evidence-Based PracticesGaps with Updated Guidelines for VAE Prevention Bundle ComplianceDistribute quick-reference guides summarizing updates and engage leadership and team leaders to advocate for compliance.LowTo ensure successful implementation of updated guidelinesA quick-reference guides of VAE Prevention Bundle ComplianceDevelop a quick-reference guide for VAE Prevention Bundle Compliance and distribute it to all relevant team members involved in patient care.Guidelines for Prevention of (VAPs) and (VAEs) in Adult, Pediatric and Neonatal Intensive Care Units ImmediatelySurveillance TeamGDIPCDistribute the quick-reference guide for VAE Prevention Bundle Compliance to 100% of all regions100%180%Annually reviewing and update VAE Guidelines by GDIPC team
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Policies may reflect outdated clinical protocols, failing to incorporate the latest evidence-based practices.Ensure updating policy in Hospitals level based on the updated guidelines.High1- Ensure hospitals implement the updated guidelines effectively.
2- Conduct periodic reviews to assess compliance with new policies and forms.		Strategy Compliance Monitoring Tool Use the compliance monitoring tool to track adherence to existing policies and identify gaps or areas needing updates.Guidelines for Prevention of (VAPs) and (VAEs) in Adult, Pediatric and Neonatal Intensive Care Units Within monthMOH BranchesMOH BranchesAchieve 100% Policy Updates.100%4090%Randomly auditing and Provide feedback
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Non-compliance with Implement VAEs Prevention Bundles.Monitoring Compliance with VAEs Prevention Bundles and share compliance rates with leadership.HighEnsuring Hospitals Complete Monitoring Sheets Monthly on Time.Strategy Compliance Monitoring Tool Ensuring Hospitals Complete the Strategy Monitoring Sheet monthly._MonthlyMOH BranchesMOH Branches100% of the monthly monitoring are completed on time.100%4090%Randomly auditing and Provide feedback
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Monitor VAE Prevention Bundle compliance and share rates with leadership to identify improvement areas.Assess adherence to the VAE prevention bundle and investigate any non-compliance incidents to identify underlying issues and address them._MonthlySurveillance TeamGDIPCAchieve 95% or higher compliance with the VAE prevention bundle across all Facilities95%#DIV/0!Regular Monitoring and Provide ongoing feedback
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Conduct a compliance validation through direct observation in hospitals with reported VAE cases, observing staff as they perform bundle components using standardized checklists, and provide feedback to hospital leadership and IC Team.MediumTo continuous improvement and adherence to best practices.VAE Bundle Observation Audit FormConduct the VAE Bundle Observation Audit based on the level of involvement in the escalation process and provide feedback accordingly_Semi-annual MOH BranchesMOH BranchesAchieve 95% or higher compliance with the VAE prevention bundle across all Facilities95%4090%Randomly auditing and Provide feedback
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Inconsistent or absent guidelines for assessing and implementing mobility interventions for patients on mechanical ventilatorsEnsure hospitals developing a protocol for assessing and safely implementing mobility interventions for mechanically ventilated patients.MediumTo implementing a mobility protocol for patients on mechanical ventilators and promoting improved recovery outcomes and reduced complications related to prolonged ventilation.Official Communication and Agreement for Developing Mobility Protocols for Patients on Mechanical Ventilators & Strategy Compliance Monitoring Tool In collaboration with a Physiotherapy expert, develop clear, evidence-based recommendation for assessing and implementing mobility interventions for patients on mechanical ventilators and share it within hospitals level.Recommendation Dissemination3 monthsGDIPC with a Physiotherapy expertGDIPCCompletion of mobility interventions for patients on MV protocols in collaboration with the Physiotherapy expert within 3 months.100%10%Randomly auditing and Provide feedback
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Ensure hospital engage a Physical therapists, occupational therapists, nurses, and respiratory therapists and discuss mobility goals during VAE multidisciplinary rounds.HighTo engage physical therapists, occupational therapists, nurses, and respiratory therapists in multidisciplinary rounds to set mobility goals for patients on mechanical ventilators.Ensure include physical therapists or occupational therapists the in multidisciplinary team to discuss and review the patient's mobility needs and progress._1 monthInfection Control Dep.Hospital100% of hospitals have included physical therapists or occupational therapists in the VAE multidisciplinary team.100%4090%Randomly auditing and Provide feedback
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Excessive use of sedatives, leading to delayed weaning, immobility, and an increased risk of VAEsEnsure hospitals implementing standardized sedation protocolsHighTo implement standardized sedation protocols to optimize sedation levels and patient outcomes.Recommendation of the main concern related to infection control Official Communication and Agreement and Strategy Compliance Monitoring Tool In collaboration with an ICU physician expert, develop clear, evidence-based recommendation.Recommendation Dissemination1 monthGDIPC with ICU Physician expertGDIPCCompletion of Recommendation of the main concern related to infection control and distribute it to all regions100%10%Randomly auditing and Provide feedback
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Inconsistencies in ventilator weaning protocols can lead to prolonged ventilation, increasing the risk of Ventilator-Associated Events (VAEs). Ensure hospitals promote communication between physicians, nurses, and respiratory therapists to discuss sedation reduction strategies and progress during patient care reviews.HighTo ensure safe, consistent, and effective ventilator weaning and improve team communication Official Communication and Agreement or Developing Sedation & weaning protocol for Patients on Mechanical Ventilators & Strategy Compliance Monitoring Tool 1 monthInfection Control Dep.Hospital100 % of Hospitals implementation of Standardized Weaning & Sedation Protocols100%4090%Randomly auditing and Provide feedback
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Non-compliance with sedation protocol can delay ventilator weaning and increase the risk of Ventilator-Associated Events (VAEs). Monitor compliance with the sedation protocol by infection control team, provide feedback to leadership and relevant departments, and address non-compliance to ensure adherence and reduce VAE risks.HighTo monitor and ensure Minimizing sedation protocol compliance, providing feedback to leadership and departments to reduce VAE risks.VAE bundle care form and Strategy Compliance Monitoring Tool Conduct regular audits to assess adherence to protocols.
Share audit results during team meetings, highlighting areas of success and opportunities for improvement.		Guidelines for Prevention of (VAPs) and (VAEs) in Adult, Pediatric and Neonatal Intensive Care Units MonthlyInfection Control Dep.HospitalAchieve 100% adherence to protocols across all audits.100%4090%Randomly auditing and Provide feedback
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Families may lack understanding of VAE, its risks, and the importance of prevention measures.Engage Families in VAE Prevention MediumInvolving families empowers them to actively participate in the patient's care, supports adherence to prevention protocols, and enhances outcomes.VAE Prevention Education Material
(English and Arabic)		Provide clear, accessible education on VAE prevention (e.g., head-of-bed elevation, oral care, and hand hygiene)._Within monthSurveillance TeamGDIPC100% of patient families receive VAE prevention education materials to all regions100%180%Randomly auditing and Provide feedback
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A shortage of ventilator equipment can compromise patient care, delay timely interventions, and increase the risk of Ventilator-Associated Events (VAEs).Ensure the hospital conduct regular inventory audits and review patient data to identify peak demand and usage and establish an escalation protocol for addressing inventory shortages.HighTo optimize inventory management and address shortages effectivelyOfficial Communication and Agreement and Strategy Compliance Monitoring Tool.Ensure the hospital conduct monthly or quarterly audits of inventory levels, focusing on critical supplies and items with high usage rates & document stock levels, expiration dates, and usage patterns to ensure timely ordering and replenishment, Flag items with low stock levels and prioritize restocking based on urgency. Develop a clear escalation protocol for inventory shortages, including steps for notifying relevant staff, procurement teams, and leadership.MonthlyInfection Control Dep.Hospital100% availability of essential items100%4090%Randomly auditing and Provide feedback
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Standardize ventilator supplies based on MOH recommendations and ensure compliance with specifications.HighTo ensure all ventilator supplies meet MOH quality standards and specifications.Official Communication and Agreement Share the list of ventilator supplies based on the latest MOH recommendations and clinical standardsWithin monthGDIPCGDIPC100% compliance with MOH ventilator supply standards.100%10%Randomly auditing and Provide feedback
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Insufficient staffing can lead to increased workloads, delayed care, and inconsistent adherence to VAE (Ventilator-Associated Events) prevention protocolsAssess Current Staffing Levels and NeedsMediumEnsuring that staffing across key clinical areas is sufficient to meet the patient care needs and uphold high standards of care..Official Communication and Agreement Share the staffing requirements based on evidence-based ratios and international standards and ensure to meet the requirement by hospitals._within 2 weeksGDIPCGDIPCCompletion of Recommendation of staffing & distribute it to all Regions100%#DIV/0!Regular Monitoring and Provide ongoing feedback
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Ensure respiratory therapist staffing meets evidence-based ratios (1:5 to 1:8).
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Ensure ICP staffing meets ICA standards.
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Ensure nursing staffing in ICUs aligns with evidence-based nurse-to-patient ratios (1:1 to 1:2).
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Inadequate management of respiratory equipment can increase the risk of (VAEs) by promoting the growth and transmission of pathogens. Ensure IC team assess Current Practices and evaluate how equipment is cleaned, disinfected, stored, and maintained and Identify and address common risks associated with the management of respiratory equipment.HighEnsure proper storage practices are followed to prevent contamination of respiratory equipment.GuidelineCreate and share a guideline for the proper management of respiratory equipment in healthcare settings, focusing on cleaning, disinfection, storage, and maintenance to prevent infection and contamination:Guideline DisseminationWithin 2 MonthsGDIPCGDIPCCompletion of guideline for the proper management of respiratory equipment in healthcare settings & distribute it to all regions100%180%Randomly auditing and Provide feedback
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Implement proper storage practices to prevent contamination (e.g., keeping clean and dirty equipment separate).High
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Intubation in non-ICU settings (e.g., emergency department, operating room, pre-hospital) may increase the risk of VAEs due to suboptimal conditions, leading to contamination, aspiration, or improper tube placement.Establish Standardized Intubation Protocols and develop Evidence-Based Guidelines for intubation across all settings, including pre-intubation preparation, aseptic technique, and post-intubation care.MediumTo ensuring consistent practices in pre-intubation preparation, aseptic technique, and post-intubation care to reduce the risk of complications, including Ventilator-Associated Events (VAEs).GuidelineCreate and share a guideline and distributed to all hospitals.Guideline DisseminationWithin 2 MonthsGDIPCGDIPCCompletion of guideline & distribute it to all regions100%180%Randomly auditing and Provide feedback
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Ensure use portable kits with all necessary sterile equipment In non-ICU settingsMedium To maintain aseptic conditions.Ensure to conduct audits of intubation procedures in various settings by IC team and review complications, including unplanned extubations or infections, to identify areas for improvement and Track and Report Outcomes Based on Intubation Location and analyze VAE rates based on the place of intubation and Investigate each VAE in trauma cases to determine contributing factors and implement targeted interventions.Randomly auditing and Provide feedback
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Ensure IC team conduct regular audit of intubation procedures in various settings.MediumTo use this data to prioritize interventions & refine protocols for high-risk settings
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Education and TrainingThere is no baseline data on staff knowledge or compliance with VAE prevention protocols, a critical gap for measuring progress and implementing improvements.Conducting a baseline knowledge assessment to identify gaps in compliance with Ventilator-Associated Events (VAE) prevention protocols and evaluate their knowledge. MediumEstablish a baseline to identify specific gaps and areas where further training or education is needed. evaluate the impact and effectiveness of future training initiatives and interventions.Questioner focused on key VAE prevention practices targeted nurses & RTs and Strategy Compliance Monitoring Tool.Create a questions focused on key VAE prevention practices_Within 1 WeekSurveillance TeamGDIPCCompletion of Questionnaire & distribute it to all hospitals100%#DIV/0!_
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Ensure IC team to assess staff knowledge of VAE prevention protocols, Identify gaps in compliance and potential barriers to adherence and Gather insights for targeted training or process improvements._Within 1 WeekInfection Control Dep.Hospital
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Lack of Staff Awareness & inadequate knowledge of VAE definitions, bundle components, and their clinical significance.Develop mandatory training modules on VAE definitions, criteria, and prevention bundle components targeting Nurses and RTs.CriticalTo develop mandatory training modules for nurses and respiratory therapists on VAE definitions, criteria, and prevention bundle components to enhance knowledge and compliance with evidence-based practices.Strategy Compliance Monitoring Tool.Ensure infection control collaborates with key stakeholders to develop comprehensive training modules and monitor coverage._MonthlyInfection Control Dep.HospitalAt least 98% of target staff complete the training.98%4090%Regular Monitoring and Provide ongoing feedback
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Use competency checklists to track staff progress and incorporate results into performance evaluations and identify training needs.CriticalTo implement competency checklists for tracking staff progress, integrating results into performance evaluations, and identifying targeted training needs to ensure consistent adherence to best practices.
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Lack of awareness of the risks associated with deep sedation or the absence of standardized sedation and weaning protocols.Provide education and training about the risks of deep sedation and its impact on weaning, mobility, and VAE prevention. MediumTo educate and train staff on the risks of deep sedation, emphasizing its impact on weaning, mobility, and the prevention of ventilator-associated events (VAEs).AnnuallyProvide 100% of required staff with educational sessions 100%4090%Randomly auditing and Provide feedback
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Insufficient staff training on intubation techniques and infection prevention, including hand hygiene, sterile gloves, and maintaining a sterile field, increases the risk of complications and VAEs.Provide Adequate Training for Staff on intubation techniques under various conditions to ensure proficiency, Focus on Infection Prevention:
Emphasize the importance of hand hygiene, use of sterile gloves, and minimizing breaks in the sterile field.		MediumTo ensure staff proficiency in intubation techniques under diverse conditions and reinforce infection prevention practices, focusing on hand hygiene, sterile glove use, and maintaining an intact sterile field._AnnuallyInfection Control Dep.HospitalProvide 100% of required staff with educational sessions 100%4090%Randomly auditing and Provide feedback
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Inconsistent skills in rapid airway assessment and intubation techniques during emergencies.Train staff on the unique challenges of managing trauma patients, including airway management, infection prevention, and sedation protocols.MediumTo equip healthcare staff with the skills & confidence to manage trauma patients effectively, focusing on airway management, infection prevention & sedation protocols through evidence-based training.PosterCreate poster of evidence-based content focused on trauma-specific challengesWithin 2 monthsSurveillance TeamGDIPCCompletion of education poster or distribute it to all regions100%180%Randomly auditing and Provide feedback
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Monitoring and EvaluationLack of analyzed VAE Rates data Analyze data after each intervention and identify areas for improvement and adjust approaches regularly and as needed.HighA systematic approach to measure the changes made after implementing the strategy, enabling the evaluation of its effectiveness in reducing complications and improving patient outcomes. Closely Monitoring VAEs Rates.Strategy Compliance Monitoring Tool and other VARS tools1- Review data from reports, dashboards, and audits to pinpoint trends, identify gaps, and highlight areas needing attention.
2- Monitoring the adherence to the implemented strategy
3- Examine recurring issues or challenges to determine their root causes.
4- Utilize diverse perspectives to refine and enhance strategies.
5- Pilot new approaches on a small scale to assess their effectiveness before broader implementation.
6- Regularly monitor the results of adjustments to ensure desired outcomes.
7- Document all changes, including the rationale behind them and the results achieved.
8- Analyze data monthly and generate reports to track progress and identify areas for improvement.
MonthlyGDIPCGDIPCCompilation of VARS Monthly Reports 100%120%Regular Monitoring and Provide ongoing feedback
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Lack of assessment of the success of VARS implemented strategy
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Failure to adjust or modify the VARS strategy plan based on evaluation results, limiting the ability.Adjust and Modify the VAE strategy plan according to evaluationHigh
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Lack of plans to sustain progress over time, hindering the ability to ensure long-term impact and continued improvement.Ensure Long-Term Impact: Develop plans for sustaining progress over timeHigh
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