PROJECT SUMMARY Although invasive mechanical ventilation (IMV) is a lifesaving treatment for about 300,000 U.S. patients with acute respiratory failure each year, it is associated with significant risks. Spontaneous awakening and breathing trials during IMV improve patient outcomes. Coordination of spontaneous awakening and breathing trials (C-SAT/SBT) is complex and significant barriers to implementation exist and adherence with C-SAT/SBT across institutions is highly variable. Although national guidelines recommend daily coordinated C-SAT/SBT in IMV patients they are underused. Telehealth-enabled remote care is positioned to improve C-SAT/SBT use. At Intermountain Healthcare, we have system-wide tele-critical care services staffed by critical care physicians, nurses, and respiratory therapists who remotely monitor and assist with patients in ICUs using real-time audiovisual communication, a systemwide electronic medical record (EMR), electronic dashboards, and clinical decision support. We recently studied the impact of implementation strategies to improve evidence-based practices for lung protective ventilation (LPV) in 3 pilot ICUs, and then adopted a Telehealth-Enabled, real-time Audit and feedback for Clinician adHerence (“TEACH”) to disseminate LPV adherence strategies to the other 14 ICUs, achieving over 90% adherence (NCT 03984175). This successful approach could help identify candidates for C-SAT/SBT protocols, prompt bedside providers to perform C-SAT/SBT, and guide execution. The specific aims of this research are to (1) adapt baseline implementation strategies and to target C- SAST/SBT using the Consolidated Framework for Implementation Research; (2) conduct a type II cluster- randomized hybrid effectiveness-implementation trial to compare a usual audit and feedback implementation approach to a usual audit and feedback implementation approach augmented with a Telehealth-Enabled, real- time Audit and feedback for Clinician adHerence (“TEACH”) to promote C-SAT/SBT; and (3) evaluate sustained adherence to the TEACH enhancement in the final year after the RCT has ended. Completion of this project will advance knowledge regarding the effective and sustainable strategies for C- SAT/SBT implementation specifically and the effectiveness generally of telehealth remote monitoring and prompting strategies to aid best practice implementation in ICUs. The proposed research builds on the study team’s existing work and has potential to develop more informed and effective care of persons with respiratory failure. Spread and scale of this telehealth-enabled, central monitoring of critical aspects of care for ICU patients is particularly important to study now, given the vulnerability of ICU staff to COVID-19 exposure.