Discussion
Development of specialized areas of care for the critically ill has 		 occurred in most hospitals in the USA [1,12,13], leading to the growth in number 		 and utilization of ICUs. Despite this growth, there is little information 		 available related to the demographics and quality of rural ICUs [2]. Without specific data on outcomes of rural ICU patient 		 care, it is difficult to evaluate quality of care issues. This lack of data is 		 of particular interest when committees have tried to rationalize and justify 		 regionalization of critical care in rural areas [2,3].
In the rural centers, the emergency room (ER) was the source of 		 admission for 56% of the ICU patients. Escarce and Kelley [14] have suggested that patients admitted to the ICU from the 		 ER often have improved survival rates when compared with patients being 		 admitted to the ICU from other areas. We might anticipate, therefore, that the 		 high percentage of admissions from ERs into rural ICUs could have a favorable 		 impact on survival rates in those ICUs. Undoubtedly, the rural ER has a 		 critical role in providing triage and stabilization of acutely ill 		 patients.
The mean ICU bed occupancy rate of 53% found in all rural hospitals 		 indicates that there was generally an ICU bed available to admit a critically 		 ill patient. ICU bed availability might be an advantage to the rural hospitals 		 by allowing prompt implementation and management of life-sustaining 		 interventions.
Higher mortality rates were found for rural patients with conditions 		 which required complicated ventilation. Mortality rates in rural patients with 		 conditions such as ARDS, MODS, and sepsis with DIC were 53%, 58% and 63%, 		 respectively. These rates are higher than the overall rural mortality rate of 		 36%. This suggests there are certain high-risk patients who may benefit from 		 transfer to a tertiary care center with greater resources and technology. The 		 significantly higher mortality rates for persons with high-risk conditions 		 suggests that these conditions might serve as primary indicators for evaluating 		 the appropriateness of transferring patients to tertiary care centers.
There are many similarities in demographics and patient 		 characteristics between the small RHs and the RRHs, including mean age, sex, 		 APACHE II score, mortality and the rate of transfer. The most striking 		 differences occur in the variation for lengths of stay in total hospital days, 		 ICU days and ventilator days. This longer length of stay for RRHs cannot be 		 explained by patient record selection alone. In looking for patients ventilated 		 for significant time periods, few were found in the small rural centers. This 		 may indicate that patients with complex medical illnesses, living in counties 		 supported by a small RH may seek acute care and admission from physicians 		 providing services in association with referral centers. This selection process 		 may contribute to the favorable mortality rates for these smaller units. The 		 longer length of stay in the RRHs is likely to have contributed to the higher 		 nosocomial event rate.
Certain limitations of this study need to be acknowledged. First, 		 since the study enrollment was limited to just 20 hospitals, it is not possible 		 to know how representative these were when compared with RHs in other 		 geographic areas. Second, our exclusion criteria eliminated patients requiring 		 only brief periods of ventilation. Had rapidly extubated patients with a good 		 prognosis been included, survival rates might have been higher. Also, exclusion 		 of patients who were ventilated briefly before transfer to another facility may 		 have affected survival rates. Despite these limitations, this study, for the 		 first time to our knowledge, provides information on rural hospital 		 demographics and patient characteristics. These baseline data constitute the 		 starting point for evaluating the quality issues associated with low patient 		 volume. Similar data collection from other rural hospitals in geographically 		 distinct areas may provide the data set required to re-evaluate the 		 opportunities for regionalization of critical care in rural areas. The concept 		 of regionalization for specific diagnoses has been supported by other studies 		 [2,15]. On the basis of the higher 		 mortality rates seen in rural patients with medical conditions resulting in 		 difficult or complicated ventilation, our data seem to support the suggestion 		 by Moscovice and Rosenblatt [3] that success in rural 		 hospitals is best actualized through 'compartmentalization' or the 		 ability to provide only that care which can be performed safely, efficiently 		 and effectively. Early triage and appropriate identification of those high-risk 		 patients who might benefit from transfer to a facility with specialized 		 technology and greater resources may further reduce the mortality currently 		 seen in patients admitted to rural ICUs.