Between the Mississippi River and the Rockies are thousands of small farming, mining, and oil and gas communities dotted across an area as large as Western Europe. Towns in states within the Midwest can be hundreds of miles apart, separated by vast expanses of wheat fields and prairie. Providing high quality care for the seriously ill is a huge challenge in this setting. In many communities there are critical access hospitals. These small but vital hospitals, located in rural areas, provide emergency and general care services to the local communities. They are small institutions and rarely have access to a deep or diverse pool of specialty clinicians to provide care for the many different medical situations they encounter. Nevertheless, they are vital to maintaining the health of the communities they serve. When someone becomes critically ill in an isolated community, the local care team at the critical access hospital, faces a dilemma:
- Choice 1: The patient can be transferred to a tertiary care center in the nearest urban area. This usually requires an air ambulance transfer, with high associated costs, and often an extended transit time. Air transfers can be difficult for critically ill patients.
- Choice 2: The team can continue to provide care in the critical access hospital – but with limited access to the expertise of intensivists, and critical care nurses.
Setting boundaries for when to transfer a patient is challenging, leading to clinicians agonizing over the best course of action. Incorporate telemedicine into your response.