Discussion
To our knowledge, TEACH will be the first clinical trial to compare a telehealth intervention augmenting a usual audit and feedback implementation versus a usual audit and feedback implementation alone in improving adherence to C-SAT/SBT in a prospective, multicenter type II hybrid effectiveness-implementation cluster-randomized setting. This trial builds on our prior collaborative work implementing computerized protocols for mechanical ventilation that drive adherence to evidence-based low tidal volume lung protective mechanical ventilation [Our study design has several strengths. First, we compare our combined strategy of telehealth real-time monitoring of patients eligible for C-SAT/SBT with usual audit and feedback to usual audit and feedback alone [We also note limitations. Optimally, the unit of cluster randomization would have been individual ICUs, which would have increased our number of clusters from 12 hospitals to 15 ICUs. All hospitals have a single ICU except for Intermountain Medical Center, whose 4 ICUs with shared respiratory therapy and nurse staffing necessitate randomizing that hospital as one cluster to prevent between-arm contamination. Also, although we have a moderate number of ICUs, all study ICUs are within a single health system, and the tested implementation strategies may not directly be applicable to ICUs in other health systems.Of note, our study does have an additional sustainment aim which will allow us to determine how well these strategies influence clinician behavior when less resources are applied to the ICUs.In summary, the TEACH clinical trial will advance the science of implementation by evaluating how telehealth services may augment a usual audit and feedback implementation of evidenced based C-SAT/SBT in mechanically ventilated patients.