PICOT statement : When observing ICU Mechanically ventilated adult veteran patients (P), does oral care every 4hr with chlorhexidine (I) compared to inconsistent oral care or other oral hygiene products (C) decrease the incident of ventilator associated pneumonia (VAP) (O) within hospitalization admission(T)? Implementation Results Dec 2021: Chart audits Initiated Jan 2022: 10 out of 30 charts showed oral care charting completed. 2 VAP patients over a 60-day review. Feb 2022: Training on oral care documentation and CHG kit for oral care every 4hr. March 2022: 20% increase in oral care documentation April 2022: Oral care toolkit roll-out for electronic healthcare record charting “Go-Live”. Follow-up training on oral care documentation and CHG kit every 4hr. May-Jul 2022: Follow-up meetings with staff and management/leadership. Discussions on issues/concerns. No issues with implementation plan. Staff still complained of being understaffed. HR recruitment in progress to get more staff hired. Hospital costs unaffected, no increase noted, remain unchanged. Aug 2022: 80% charting compliance noted from EHR oral care toolkit audit. Sep 2022: 1 VAP incident due to patient decline in health from medical complications and remaining ventilator dependent. Chart audit reviewed and determined that oral care was completed as recommended every 4hr.