hospital, such as a cardiac catheterization team on-call or a pediatric trauma center, and the distance and time to a receiving facility Many EMS systems are now specifying certain hospitals as approved POE for conditions such as stroke, acute coronary syndrome, or pediatric trauma This assures that the patient is going to a facility that can best manage their condition Regionalization is “a process of organizing resources within a geographic region to ensure access to medical care of a level appropriate to a patient’s needs, while maintaining efficient use of available resources.” The purpose is to ensure that services and resources are optimally allocated and used to improve the health of patients across an entire region Regionalization incorporates categorization to delineate available regional resources, accreditation to verify institutional commitment to provide the needed services, and designation to preclude the inefficient duplication of resources In the 1980s, evidence supporting the regionalization of trauma care was published, and the ACS-COT formed the trauma center verification review program in 1987 The past decade has seen the development of regionalized systems of care for ST-elevation myocardial infarction and stroke Pediatric emergency care regionalization in the United States is still undergoing development and refinement It has been recognized as a priority by the IOM, and the EMSC program has published a Pediatric Regionalization of Care Primer, available at https://emscimprovement.center/programs/sproc/sproc-grantresources-and-products/ The primer is an excellent resource for those who are interested in organizing shared resources to optimize access to pediatric specialty care PEDIATRIC PREHOSPITAL AIRWAY MANAGEMENT Respiratory arrest is the most common cause of pediatric cardiac arrest and is associated with three conditions seen frequently in the prehospital setting: trauma, respiratory distress, and seizures Emergency airway management can be lifesaving for critically ill children; however, it requires a significant amount of training and experience and a broad range of skills in evaluation and interventions The high-risk and low-frequency nature of pediatric airway management allows for controversies in current recommendations ETI is taught in the majority of paramedic schools and has been accepted in the scope of practice for paramedics for decades The current literature on pediatric prehospital ETI highlights several shortcomings, and few studies have shown improved patient outcomes Errors and adverse events are frequent, with successful intubation rates documented between 60% and 85%, while complications such as esophageal intubation or unrecognized tube dislodgement are noted in 2% to 25% of successful intubations In addition, skill deterioration is almost inevitable, as only 1% to 5% of pediatric patients treated in the prehospital setting receive airway management In some systems, paramedics may attempt pediatric intubation no more than once a year The largest randomized controlled trial of ETI versus noninvasive bag-valve-mask (BVM) ventilation was published in 2000 The study included 830 patients under the age of 13 in two large metropolitan counties served by 56 EMS agencies Results demonstrated no difference in mortality or neurologic outcomes across the study population; however, the results also noted that scene time and total prehospital time was significantly longer in the ETI group Retrospective review of the National Pediatric Trauma Registry revealed significantly higher observed versus expected mortality for children intubated in the prehospital setting across all injury severities Both of these studies were performed before the common use of rapid sequence intubation (RSI) medications Newer technologies can aid in placement of endotracheal tubes or provide enhanced ventilation without an endotracheal device Video laryngoscopy has been employed in the hospital setting to improve airway visualization and supervision of trainees Studies in a simulated prehospital setting have shown promise for its widespread use; however, none of these studies have addressed pediatric patients Alternatives to ETI include supraglottic airway devices, such as the laryngeal mask airway device and laryngeal tube device The laryngeal mask airway is available for use in smaller patients, including neonates, while commercially available laryngeal tubes, like the King airway (Kingsystems, Noblesville, IN), are not suitable for use in patients under 10 kg Available research on supraglottic devices in pediatric patients is limited to studies performed in the operating room or simulation setting, and further studies on the use of these devices in the prehospital setting is needed Chemically assisted intubation with medications, drug-facilitated intubation or RSI, is commonly used in the ED setting and has wide use in U.S aeromedical and European EMS systems An international meta-analysis including pediatric patients has documented increased ETI success rates with the use of RSI Perspectives from an expert panel on RSI for head-injured patients concluded that literature examining RSI by EMS systems is inconclusive with differences in outcomes, possibly related to EMS and trauma system characteristics This group