Context: Ambulance transport of pediatric trauma patients to designated trauma centers in cases of moderate and severe injury is not always performed, which has been shown to result in poor treatment outcomes. Determination of factors involved in inappropriate patient transport, especially in rural areas, remains an important avenue of research. Purpose: To identify factors involved in ambulance transport of pediatric patients sustaining moderate-to-severe head injury to nondesignated trauma centers in rural North Dakota. Method: Emergency medical service ambulance records for North Dakota from 1995 to 2000 were used. One hundred fifty-six cases of pediatric head injuries with Glasgow Coma Scale scores <12 and transported by rural ambulance squads were selected. A logistic regression analysis was conducted to identify a set of significant predictors of cases of inappropriate deliveries to acute care facilities with no trauma-center designation of any level (II-V). Results: Greater distance (mean = 19.96 miles) to the nearest trauma center and shorter distance traveled by the ambulance squad to the receiving facility (mean = 19.07 miles) corresponded to higher probabilities of mistriage, especially when a child was Native American (16 times more likely) and the transportation was conducted in the winter (9 times more likely). Conclusions: Timely delivery of pediatric trauma patients to designated trauma centers is encumbered in the winter, particularly in Native American communities, because of the greater traveling distances, which could be counteracted by better mobilization of available resources aimed at administration of optimal trauma care.