Randomization and treatment assignment
The unit of randomization will be the hospital for this cluster-randomized clinical trial. The 12 study hospitals will be assigned by block randomization, stratified on baseline ICU-ventilated patient volume, to receive either the usual supervisor-led intervention alone (6 hospitals) or the TEACH intervention in addition to the usual supervisor-led implementation approach (6 hospitals). Block randomization by hospital and ventilated patient volumes ensures balance between treatment arms. All hospitals have one ICU except for the largest hospital, Intermountain Medical Center, with four ICUs. Since individual ICUs at this hospital share respiratory therapist, nurse, and physician staffing, all ICUs were randomized as one cluster and analyzed together to prevent between-arm contamination. Stratified randomization to TEACH versus usual implementation approach will occur in three steps: (1) randomize the two largest volume sites according to baseline ICU-ventilated patient volume, one site to usual implementation alone and one to usual implementation plus TEACH, (2) randomize the next two largest-volume sites in the same 1:1 fashion, and (3) randomize the remaining eight sites with four sites randomized to usual supervisor-led audit and feedback alone and four randomized to TEACH plus usual supervisor-led audit and feedback.