Capacity Strain in US Children’s Hospitals: A Mixed-Methods Study of Measurement and Mitigation

BACKGROUND: Regionalization of pediatric inpatient care has concentrated demand within children's hospitals and increased concerns about capacity strain. Although hospitals track metrics and deploy mitigation strategies, little is known about how institutions define strain and translate signals into operational decisions. METHODS: We conducted a national mixed-methods study of US children's hospitals. Operational leaders from hospitals receiving Children's Hospitals Graduate Medical Education funding completed a cross-sectional survey assessing strain metrics, mitigation strategies, and decision drivers. We used descriptive statistics to summarize responses. We then interviewed a purposive sample to explore how hospitals interpret metrics and make mitigation decisions. We analyzed qualitative data using thematic analysis and integrated findings with survey results. RESULTS: Forty-five of 47 eligible hospitals responded (96%), and 20 leaders completed interviews. Among metrics, occupancy indicators were most common (>98%). However, most hospitals lacked full alignment between metrics identified as important indicators of strain and those used to trigger mitigation. Early strategies included encouraging discharges, activating staff, and opening additional bedspace, whereas diversion or procedure cancellations were implemented later despite being perceived as relatively more effective. Qualitative analysis identified four themes: mismatch between measured capacity and experienced strain; adaptive capacity normalizing chronic strain; institutional commitments to access sustaining exposure to strain; and escalation of strain requiring institutional credibility thresholds. CONCLUSIONS: Pediatric hospitals track extensive operational metrics, yet strain recognition and mitigation are shaped by institutional priorities, professional norms, and measurement limitations. Improving strain management may require multidimensional measurement approaches and policy-level changes to strengthen pediatric care infrastructure.