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Centralization of PICUs requires a transport system that delivers patient outcomes equivalent to that of the same institution admissions. Our aim was to evaluate how pediatric critical care retrieval, distance traveled, and referral center level of ICU support impact on outcomes in unplanned admissions.Retrospective cohort study.The national PICU in New Zealand.A total of 5,609 (45% retrieved) unplanned pediatric admissions (< 15 yr) between January 1, 2004, and January 1, 2014.None.Data analyzed included case-mix, source of admission, diagnostic category, Pediatric Index of Mortality score, PICU-specific resource use, distance traveled, transport duration, and referral hospital ICU level. Outcome measures were crude and risk-adjusted PICU mortality and PICU length of stay. Compared with nontransported admissions, retrieved children were younger, more frequently admitted outside normal working hours, had higher predicted mortality (median Pediatric Index of Mortality score, 4.7% vs 1.5%; p < 0.001) and PICU-specific resource use (respiratory support, vasoactive infusions, and renal replacement therapy). The transport cohort had greater crude mortality rates (8.6% vs 5.6%; p < 0.008) and a median of 29 hours longer PICU stay. There was no significant difference in risk-adjusted mortality between the cohorts (observed/expected mortality ratio for retrieved patients, 0.84 vs nontransported patients, 0.91; p = 0.73). Neither distance traveled (median, 135 km), transport duration (median, 4.4 hr), nor the level of ICU at the referral center had a significant effect on risk-adjusted PICU mortality in the retrieved cohort.Children retrieved to the national PICU in New Zealand have greater predicted mortality risk and PICU-specific resource use than nontransported patients. There is no significant difference in risk-adjusted mortality between retrieved and the same institution admissions. Critically ill pediatric patients can be transported long distances by specially trained and equipped transport teams, without an increase in risk-adjusted PICU mortality.