The 5 Pillars Of Bolstering Emergency Medicine In Rural America

by | Jun 14, 2021

The ACEP Rural Emergency Care Task Force Summary 2020 recommends a robust plan to provide supplemental training and enhance the quality of care patients receive in rural EDs, as well as to increase the confidence of the practitioners staffing those facilities, including non-EM Trained Physicians, PAs, and NPs. Completing this recommended training is not meant to be equivalent to an emergency medicine residency, but is a minimum standard of training for any provider to work clinically in the ED. This proposal consists of 5 pillars of supplemental education and support.

The 5 Pillars are:

  1. Foundational Training
  2. Airway Training
  3. Simulation Training
  4. Work in a High Volume ED With EM Trained/Boarded Physicians
  5. Telemedicine Support/Oversight

Pillar 1: Foundational Training

The first step put forth by the Rural Emergency Care Task Force is to provide broad foundational training to non-EM trained physicians, PAs, and NPs. Many of these clinicians are already practicing emergency medicine and have different specialties and strengths depending on where they received their education and experience. While picking up knowledge and adapting to different situations is an excellent skill, it’s important that every EM provider has foundational knowledge to build from.

Emergency Medicine Core Training is the most robust supplemental online emergency medical training available today. Many organizations have vetted EMCT and have implemented it as their premier onboarding foundational training, including the Mayo system and Team Health. EMCT is also included in the aforementioned Rural Emergency Care Task Force Summary, as it provides a breadth of foundational knowledge that’s critical for any clinician practicing emergency medicine in EDs across America. 

This pedagogical program consists of 14 modules that cover a range of vital systems and subjects, from cardiovascular emergencies to neurologic and psychiatric emergencies to toxicologic and environmental emergencies, and much more. Each module starts with the foundation of Anatomy & Physiology and finishes with scenario based “workup, diagnosis, and management” of emergency patients. All modules follow an academic, evidence-based approach to patient care. The modules bring students right to the bedside and include videos of encounters with and procedures on real patients (not mannikins or cadavers). Students will also learn from radiographic imaging, ECGs, lab studies and more, and since the courses are housed entirely online, they’re accessible anytime, anywhere with a stable internet connection. EMCT is ideal for fulfilling the first step in the Rural Emergency Care Task Force’s plan.

Pillar 2: Airway Training

Any provider who has practiced emergency medicine knows the critical importance of airway training. In airway-related emergencies, mere seconds can decide whether or not the patient recovers. It’s vital that a provider has the knowledge, education, and experience to make quick and correct decisions without hesitation in these circumstances. This is why the Rural Emergency Care Task Force’s second recommended pillar of supplemental education and support is airway training.

An excellent program that exists that can meet the need for this training is The Difficult Airway Course. They offer the experience of a 50-member faculty made up of experts from a variety of specialties, and like EMCT, their program is dedicated to providing evidence-based education. They also offer both in-person and virtual courses to suit their students’ needs. 

The Rural Emergency Care Task Force Summary recommends an advanced airway course to fulfill this second pillar of supplemental education and support for non-EM trained physicians, PAs, and NPs. The Difficult Airway Course is an optimal program to fulfill this need and provide this critically important training.

Pillar 3: Simulation Training

The third pillar of the recommended plan is simulation training for providers. The supplemental training available online is ideal for laying the foundation of necessary foundational knowledge, but the most effective way to retain that knowledge is via hands-on experience in an educational setting.

The Rural Task Force Summary includes mention of the CALS program (Comprehensive Advanced Life Support) which is a program that began in Minnesota in 1996 for some of the same reasons that the ACEP Board of Directors convened the 2020 Rural Emergency Care Task Force: to ensure that patients in rural America, far away from large urban hospitals, have access to quality critical care.

The CALS program has a four-element approach, focusing on emergency skills and knowledge, effective provider teams, patient-focused care and systems, and appropriate equipment. Their main goal is to ensure that small EDs with limited resources have the knowledge they need to make the most of those resources. 

Pillar 4: Work in a High Volume ED With EM Trained/Boarded Physicians

The most effective additional training any emergency medicine provider can receive is real hands-on experience treating a wide variety of patient encounters under the supervision of a board-certified emergency physician. That’s why the fourth step recommended by the Rural Emergency Care Task Force Summary is supervised work in a large volume ED.

Non-EM trained physicians, PAs, and NPs practicing in rural America can gain skills, knowledge, and experience from their work in small volume EDs, but are far less likely to see as wide a range of emergency situations as they would in an ED with more patients. Rotations to urban hospitals can provide this additional experience and help them to emulate the care provided by specialists in emergency medicine.

Pillar 5: Telemedicine Support/Oversight

The fifth and final step in the Rural Emergency Care Task Force’s recommendations is support for non-EM trained physicians, PAs, and NPs in rural areas from board certified emergency physicians via telemedicine. In large urban hospitals, if a provider has a question about treating a patient, they can normally simply ask their attending emergency physician. However, in many small EDs in rural areas today, the opportunity to get questions answered immediately is unavailable.

The solution to this is telemedicine, which makes it possible for a board certified emergency physician to always be on-hand even if they’re not physically present. This also provides a great opportunity for emergency physicians to expand their practice because it grants the ability to live urban and still improve rural healthcare.

High quality telemedicine support has been proven to be effective by organizations such as Avera e-CARE and the Mayo system. Avera is the nation’s largest telehealth network, and can provide telemedicine services to EDs across the country. This makes them a fitting solution for helping to address the demand for telemedicine support for rural EDs. The Mayo system has the whole package; it addresses all 5 pillars of the Rural Task Force Summary, including telemedicine oversight of its rural EDs.


The 5 Pillars recommended by the Rural Care Task Force Summary 2020 are designed to work together to uplift both providers and the quality of patient care across America. The data in the summary shows that many non-EM trained physicians, PAs, and NPs are practicing emergency medicine in rural EDs across the country without a minimum onboarding educational standard, and often without access to the support of a board-certified emergency physician. The purpose of this plan is not to replace EM board certification as a standard, but to improve patient safety by supporting those already practicing in rural ED’s that have not had adequate and consistent training in emergency medicine. Applying these 5 pillars of training to all rural EDs will improve patient care and provider confidence.