Highlight
1. Most emergency departments (EDs) see very few critically ill pediatric patients annually.
2. Nearly one-third of EDs had at least one year without any pediatric critical illness encounters.
3. A minority of critically ill children treated at low-volume EDs were located within a 15-minute drive of a high-volume ED.
4. Direct transport to high-volume centers is unlikely to be a universal strategy to optimize care for critically ill children.
