Background: The COVID-19 pandemic has necessitated rapid changes in healthcare delivery in the United States, including changes in the care of hospitalized children. Our study aimed to identify the major changes in inpatient pediatric healthcare delivery and potential learnings from these changes.

Methods: We conducted semi-structured interviews for this qualitative study. We purposefully sampled hospitals in the six U.S. states with the highest hospitalization incidence per million residents during the first COVID-19 surge in Spring 2020 (NY, NJ, DC, MA, CT, LA). We recruited 2 participants from each hospital (mix of hospital administrators and front-line clinicians), and we recruited an equal mix of participants from community and children’s hospitals. We analyzed interview data using constant comparative methods to develop a conceptual model of major healthcare delivery changes and learnings during the COVID-19 pandemic.

Results: Twenty-four participants from 12 hospitals were interviewed. Participants described rapid development of policies and protocols by hospital leaders to: 1) ensure adequate clinicians/staff for surges of patients with COVID-19, 2) ensure adequate space and supplies, 3) direct use of personal protective equipment, and 4) guide medical management of patients with COVID-19. Hospital leaders optimized communication by conducting regular meetings in which leaders would relay information on the current state of the COVID-19 pandemic and hospital census, as well as upcoming changes in policies and protocols. In the setting of declining volumes of hospitalized children, pediatricians and other clinicians often modified their clinical roles to instead care for hospitalized adults. This modification was successfully supported by developing mixed care teams supported by adult hospitalists, new educational resources and training materials, and telehealth supports. Participants described negative impacts of the COVID-19 pandemic on clinicians’ mental health, as well as helpful supports for clinician well-being, including mental health resources, wellness activities and spaces, and housing supports. Finally, participants described experiences diagnosing and managing multisystem inflammatory syndrome in children (MIS-C), including diagnostic uncertainty and evolving management for this novel disease.

Conclusions: This national study of healthcare delivery for hospitalized children during the COVID-19 pandemic found that 1) optimizing communication was key to rapidly changing hospital policies and protocols, 2) developing educational and training resources was critical to supporting clinicians in modified roles to newly care for hospitalized adults, and 3) providing mental health supports was important to address negative impacts on clinicians’ mental health. These findings can assist hospital leaders in this ongoing pandemic and future disaster planning.