Frameworks to maximise effective intervention sustainability in a hospital setting - a systematic review

Background
Many effective interventions introduced in hospital settings are not sustained. Although the reasons for this are complex, research suggests that the use of theoretical frameworks and models might increase sustainability. Such frameworks aim to address factors that impact on sustainability. The literature
around these frameworks has provided significant contributions to the implementation field, however, there is little consensus around how such theoretical frameworks are usefully applied in practice.

In response we have conducted a systematic review of theoretical frameworks that have been used to address sustainability of interventions. This review focuses on hospital-based interventions, as hospitals have been the focus for a series of implementation projects in recent years. They are challenging and
complex environments. Understanding factors that lead to sustained implementation in hospital settings is therefore likely to be of considerable research and practice benefit.

Methods
A systematic review of eight electronic databases was conducted between 01/01/08 and 28/02/18. We also hand searched the Implementation Science journal and reference lists of included articles. One reviewer screened all titles, removing any obviously irrelevant titles. Two reviewers then independently
screened any potential abstracts, and full text papers against the selection criteria. Study quality was assessed independently by two reviewers, using tools appropriate to the design of the study. We used a standardised pre-piloted form and extracted the following data: sustainability frameworks, study time frame, intervention/programme aims and components, study context and participants. Data on barriers and facilitators to sustainability were extracted by using a data extraction sheet where each barrier/facilitator per study was mapped onto existing sustainability frameworks. Models, theories and frameworks were categorised and coded according to level of theoretical visibility and typology. Key findings were brought together within a narrative synthesis.

Outcome
The search identified 154,757 records; we screened 14,626 abstracts and considered 431 full text papers, of which 34 studies were included in the evidence synthesis. The systematic review revealed that sustainability is poorly reported. Less than 10% of included studies (3/34) reported all sustainability
constructs we identified. Where frameworks were applied rather than developed by the authors, they were used both individually and in combination. The majority of frameworks were used to understand and/or explain what influences implementation outcomes, including sustainability. Frequently reported barriers to sustainability were individual factors, management of staff and staffing
levels. Frequently reported facilitators highlighted leadership, education and training, support from central functions and adequate resourcing as key drivers underpinning successfully sustained interventions.

Conclusion
Our review confirms the methodological challenges of sustaining interventions in practice. It also provides a contemporary insight into how frameworks have been used for sustaining interventions in hospitals. Key factors for sustaining an intervention have been identified, and inform what is required of sustainability frameworks if they are to have a positive impact on practice. In particular, we reflect on sustainability as part of implementation, and promote the need to address it as a dynamic, evolving process. Our review also provides empirical evidence that more consistent and complete reporting of sustainability is needed if we are to learn best-practice for implementation work going forward.