Since the combined elements of the ‘VAP care bundle’ were applied together it was not possible to evaluate the contribution of each one. In combination we observed a relative risk reduction of 0.53, whilst previously published evidence suggests that chlorhexidine confers a relative risk reduction of 0.56 (Chan et al., 2007) and oropharyngeal suction confers a reduction of 0.32 (Chao et al., 2008). Most literature exploring the impact of brushing teeth incorporates chlorhexidine, however in a small study (n = 53) by Yao et al. (2011) brushing with distilled water alone was found to significantly reduce the incidence of VAP and dental plaque. All elements of our current oral care regime appear to be supported by our internal evaluation as well as by published literature.