Rural EDs In America: A Closer Look

by | Jan 11, 2022

Tan dog with stethoscope around it's neck

Although they are generally much smaller compared to their high-volume urban counterparts, rural emergency departments still represent about half of the EDs across the country. According to the ACEP Rural Emergency Care Task Force (RTF) Summary 2020, “Rural ED’s represent 53% of all hospital emergency departments in the US and 24% of ED patient volume” (1).

The Federal Office of Rural Health Policy (FORHP) listed 2,198 hospitals in rural areas in 2019. The largest number of the facilities in this group are categorized as Critical Access Hospitals (CAH) which are also “the most rural and have the lowest average acute care beds” (1). Other Federal designations include Rural Referral Centers and Sole Community Hospitals (SCH), the latter of which are usually the sole source of care for isolated residents. Congress also recently approved a “Rural Emergency Hospital” designation, which may supplant some rural hospitals and leave essentially a “standalone” ED in the community.

Data reveal that the number of Rural EDs have been declining in recent years. The RTF Summary states that “between 2002 and 2018, there were 82 rural ED openings and 137 rural ED closures, with a net loss of 55 rural EDs over the 17 years” (1). This comes at a time when it’s clear that these facilities are also seeing an increase in how much their patients depend on them. An article published in the Spring of 2019 titled Trends in Emergency Department Use by Rural and Urban Populations in the United States by Margaret B. Greenwood-Ericksen, MD, MS and Keith Kocher, MD, MPH found that “Rural EDs experienced greater growth in ED use simultaneous with increased pressure as safety-net hospitals” (2). This decline in the number of EDs serving rural areas has resulted in increased pressure on the remaining clinicians and facilities staffing other regional EDs. Because of the limited resources, rural hospitals require government subsidies to succeed financially, since patient care reimbursement alone only covers a fraction of necessary expenses. Even with the current greater availability of emergency medicine (EM) trained/boarded physicians, many rural EDs have found it financially difficult to recruit and retain these EM specialists.

Hospitals and health systems have moved to reduce financial burden by recruiting NPs and PAs to staff their very low volume rural EDs. This is allowed by the Centers for Medicare and Medicaid Services (CMS) as they have a Condition of Participation (CoP) for CAHs (§ 485.618) that states that they will allow payment to MDs, DOs, PAs, and NPs who work solo at CAHs. The CoP further states that these physicians, PAs, and NPs must be trained or experienced in emergency care. CMS, though, does not go on to define what “EM trained” means. A survey of a large number of rural ED providers was carried out by the ACEP RTF, and it was found that the current standard for getting credentialed as an ED provider in a rural ED is a professional license as a MD, DO, PA or NP, and certifications in ACLS, ATLS, and PALS. Clearly, these certifications alone do not come close to defining competency in emergent care and that is why we previously wrote a blog on this topic (see Why Physicians, PAs, and NPs Need Specific Training in Emergency Medicine for more details).

ACEP, as an organization representing EM physicians and ED patients presenting to all EDs in the US, is grappling with this quagmire of wanting to staff all emergency departments with EM trained and board certified emergency physicians, but recognizing that financial constraints of the rural hospitals and lack of motivation by many EM trained physicians to move rural are two major barriers to making this a reality. Rural EDs can begin to fully financially support EM trained/boarded physicians at volumes greater than 10,000 patients annually. At volumes of 5,000 – 10,000 annually, subsidies are required to have EM physicians staff these EDs, but this is the ideal. At volumes less than 5,000 it becomes difficult to financially support EM trained/boarded physicians but some EDs still manage to do it. At volumes less than 2,500 annual patient ED visits, finances nearly always necessitate another provider model. It must be recognized, though, that the current condition of allowing new PA or NP graduates to work solo in a rural ED, no matter how low the volume, is reckless on the part of our health system and dangerous for patient care. This needs to change! The ACEP RTF has outlined a 5 step plan as a minimum, but achievable, standard of Emergency Medicine training for providers to work in any ED (outlined in more detail here). Telemedicine support by EM-trained/boarded physicians is a major part of this plan and is an opportunity for these highly trained specialists to live urban while still being able to greatly improve the quality of rural healthcare and make rural ED care more equitable compared to urban EDs. An additional level of patient safety should be added by having an EM boarded physician serve as medical director of every ED in the country.

Clinicians staffing rural EDs have been learning to make the most of limited resources as they care for their patients. Many of the physicians working in these hospitals have served their communities for years, even decades. While the trend of Rural ED closures can be disconcerting, offering more training and support to practicing clinicians can only help improve competence, confidence, and overall patient safety across the country. A great first step to learning clinical emergency medicine is the EMCT program. If you have questions about onboarding physicians, PAs, or NPs at your hospital or health system, please contact us at in**@em************.com.


  1. Carlos A. Camargo, Jr. et al. (2020) ACEP Rural Emergency Care Task Force Summary
  2. Greenwood-Ericksen MB, MD, MSc and Kocher, K MD, MPH “Trends in Emergency
    Department Use by Rural and Urban Populations in the
    United States” PubMed Central 2019