Over the last few years, many hospitals and clinics have been forced to close due to staffing, low reimbursement rates, and increasing operational costs. This healthcare crisis has especially affected rural areas in the US: more than 20 percent of our nation’s rural hospitals (or 430 hospitals across 43 states) are near collapse, and about 41 percent of rural hospitals operate at a negative margin, meaning they lose more money than they earn from operations. Since 20 percent of Americans live in a rural county, this would greatly impact patient care in both the short and long term. While the immediate medical consequences are obvious, the impact on supporting services such as pharmacies and clinics will also be substantial. Rural areas will be left without routine primary care, maternity care, or emergency care. 

The downstream effects will undoubtedly be felt in neurocritical care, too. With a loss of routine primary care services there will be an increase in untreated hypertension, diabetes, heart disease, sleep apnea, asthma, and many other diseases. The consequences of this will likely lead to an increase in patients with stroke, subarachnoid hemorrhage, and status epilepticus. Meanwhile, patients with acute issues such as traumatic head injury and seizures will be unable to receive early resuscitation and stabilization, and they will lose access to organized networks that can ensure timely transfers to larger referral hospitals. Importantly, rural patients will also lose access to early stroke interventions that have greatly impacted mortality and morbidity worldwide. 

Our ICUs will now have to care for more patients who are excluded from early treatments because they arrive outside of the therapeutic window required for positive outcomes. I predict that this will cause an increase in ICU lengths of stay because of patients who require longer-term mechanical ventilation and ultimate placement in long-term care facilities. This downstream loss of rural care will rapidly affect the financial health of large referral hospitals and create bed shortages which will disrupt our operations and our ability to provide world-class neurocritical care. This influx of patients will also greatly affect staff wellness and may lead to burnout and staff losses in an already stressed system.

As a group of dedicated health professionals who provide care to a diverse patient population, we must act now. We need to contact our local, state, and federal elected officials and inform them that this is a recipe for disaster. Our institutions should also act to create urban-rural partnerships to provide clinical assistance to struggling facilities. For example, some services such as expensive imaging may be more easily provided by mobile imaging vans, which would mean that rural hospitals would not need to invest in high-priced technology. Other technology can also play a role in aiding rural health care, such as virtual access to specialists and shared electronic medical records that can improve healthcare delivery.  We all appreciate that early access to primary care and close follow-up can decrease the need for expensive critical care services, so we need to lend our voices to prevent future admissions to our ICUs.