•Helicopter emergency medical services (HEMS) has been shown to be overutilized, and studies have been mixed in showing that their use improves survival.•Evidence in pediatric trauma literature, specifically for interfacility helicopter transfer, is limited. No current clinical criteria or guidelines exist to identify patients most appropriate for HEMS transport.•This study focuses specifically on interfacility pediatric trauma transport and utilizes one of the largest cohorts within the literature.•We assess operating room interventions as a surrogate for determining appropriate transport to our level 1 pediatric trauma center, while also comparing patients transferred by helicopter to those transferred by ground. Helicopter emergency medical services (HEMS) are intended to expedite care to definitive management. Studies are inconclusive in demonstrating appropriate use. We aimed to examine emergent interventions after interfacility helicopter transport (IHT) to our pediatric trauma center. Trauma patients 0–18 years undergoing IHT or interfacility ground transport (IGT) to our institution from January 2011-December 2020 were studied. We evaluated the rate of IHT patients undergoing emergent (1 h), urgent (6 h), and semi urgent (48 h) operating room (OR) intervention compared to IGT as a measure of appropriate transport. Inclusion was met by 1003 IHT and 7829 IGT patients. OR intervention was required in 29.6% of IHT patients, emergent in 1.3%, urgent in 12.6%, and semi urgent in 10.6%. Overall, IHT patients had higher mean injury severity score (ISS; IHT:14.5; SD:11.0 vs. IGT:6.0; SD:5.0; p < 0.01) and lower GCS (IHT:12.0; SD:4.9 vs. IGT:14.8; SD:1.4; p < 0.01), though over triage (ISS ≤ 15) occurred in 67.9% of patients. More interfacility helicopter transport patients underwent emergent and urgent procedures compared to interfacility ground transport patients; however, emergent intervention was not required in 98.7% of interfacility helicopter transport patients and over two thirds had ISS ≤ 15, possibly suggesting overutilization of interfacility helicopter transport for pediatric trauma patients at our center. Level III