Rural Hospital Emergency Departments Research Articles

Appropriateness of antibiotic prescribing for patients with sepsis in rural hospital emergency departments.

This was a multicentre retrospective cohort study of adult patients (≥18 years) presenting with a process associated International Classification of Diseases code (ICD-AM-10) pertaining to sepsis between January 2017 and July 2020 to rural Emergency Departments. Our primary outcome was antibiotic appropriateness as defined by the Australian Therapeutic Guidelines (for antibiotic selection relative to infecting source) and the National Antimicrobial Prescribing Survey tool. Our secondary outcome was in-hospital mortality. Relevant clinical and non-clinical, physiological and laboratory data were collected retrospectively. Multivariate logistic regression was used to estimate the odds of both inappropriate antibiotic prescribing and in-hospital mortality based on clinical and non-clinical factors. A total of 378 patients were included who primarily presented with sepsis of unknown origin (36.8%), a genitourinary (22.22%) or respiratory (18.78%) source. Antibiotics were appropriately prescribed in 59% of patients. A positive Quick Sequential Organ Failure Assessment score (qSOFA) (odds ratio [OR] = 0.49; 95% confidence interval [CI], 0.29-0.83), a respiratory infection source (OR = 0.5; 95% CI, 0.29-0.86) and documented allergy (OR = 0.42; 95% CI, 0.25-0.72) were associated with a lower risk of appropriate prescribing in multivariate analysis. Forty-one percent of patients received antibiotics within 1 h of presentation. Inappropriate antibiotic prescribing was not associated with in-hospital mortality. The rates of appropriate antibiotic prescribing in rural Emergency Departments for patients presenting with sepsis is low, but comparable to other referral metropolitan centres.

Implementing intimate partner violence (IPV) screening within emergency departments – Barriers, challenges and enablers experienced by intimate partner violence practice change champions

AimTo identify the barriers, challenges, and enablers that clinical champions experience whilst implementing Intimate Partner Violence (IPV) screening within Emergency Departments (EDs). BackgroundChampions support the introduction of IPV screening within EDs. This paper shares new knowledge about IPV practice change champions: barriers, challenges and enablers they experienced in their efforts. DesignBetween 2017-2019, semi structured qualitative interviews were conducted with 23 individuals who identified as champions, working to introduce routine IPV in two rural tertiary hospital Emergency Departments. An interpretive framework and process of constant comparison was used to thematically analyse data from transcribed interviews. ResultsChampions identified barriers, challenges, and enablers that they experienced. Enablers included: support for the work of champions; champion leadership and collegiality; and training for the champion role. Challenges and Barriers included: resistance to a change in the focus of practice; and workflow and workload. Conclusions and implicationsNurse champions can effectively support IPV practice change but face certain barriers, challenges and enablers. Nurse managers can use this information to support champions to undertake their role effectively in order to better meet the needs of individuals experiencing IPV.

BEFAST Assessment in a Rural Community Hospital - the BIRCH Study (P6-9.008)

<h3>Objective:</h3> To assess utilization of BEFAST in the emergency department (ED) of a rural hospital after inclusion in the acute stroke protocol. <h3>Background:</h3> There are known regional disparities in treatment rates with thrombolysis and thrombectomy for acute ischemic stroke. BEFAST has been implemented in acute stroke protocols to aid in recognition of signs of stroke, but its utility in a rural ED is not well known. In February 2022 the acute stroke protocol was updated to include the BEFAST screening tool. <h3>Design/Methods:</h3> A retrospective chart review was conducted on all patients with an ED diagnosis of stroke, dizziness, vertigo, imbalance, lightheadedness or visual disturbance for six months before and after BEFAST stroke protocol implementation. Primary outcomes included appropriateness of tool utilization and subsequent activation of the acute stroke order set. Secondary outcomes were treatment with tenecteplase and thrombectomy, door to needle time, and door to transfer time. Pre- and post-implementation cohorts were compared. <h3>Results:</h3> In the pre- and post-implementation cohorts there were 151 and 210 patients for whom a BEFAST was appropriate. BEFAST was utilized in 54% (n=81) in the pre-implementation cohort and 77% (n=161) in the post-implementation cohort (p&lt;0.01). The acute stroke order set was activated by the ED in 37% (n=30) pre-implementation and 47% (n=76) post-implementation (p&lt;0.01). Five patients were treated with tenecteplase, thrombectomy or both in the pre-implementation cohort and 5 post-implementation. Median time door to needle was 44 minutes pre-implementation and 58.5 minutes post-implementation. Median door to transfer times were 214 minutes and 141 minutes respectively. <h3>Conclusions:</h3> <b>Although BEFAST can be successfully utilized in the rural hospital emergency department, utilization does not always result in activation of the acute stroke order set. Reasons for failure to activate the acute stroke order set in the rural ED need to be elucidated.</b> <b>Disclosure:</b> Caroline Knight has nothing to disclose. Ms. Hawkins has nothing to disclose. Ms. Merrifield has nothing to disclose. The institution of Dr. Stein has received research support from American Heart Association. Dr. Stein has nothing to disclose.

Pharmacist-led urine culture follow-ups in a rural emergency department

BackgroundUrinary tract infections (UTIs) are a common indication for antibiotic prescriptions in the outpatient setting. With rising antimicrobial resistance, eliminating unnecessary antibiotics is critical. Previous research has shown that pharmacist-led antimicrobial stewardship in the emergency department (ED) setting can reduce the number of unnecessary antibiotics and increase appropriate antibiotic prescribing. By expanding the scope of ED pharmacists to include antimicrobial stewardship initiatives, rural EDs can better justify pharmacy involvement in the ED. ObjectiveTo determine whether pharmacist review of urine cultures in a rural ED leads to an improvement in antimicrobial stewardship outcomes. MethodsThis was a hybrid, quality improvement study conducted in a 12-bed, rural hospital ED. Data were collected from October 15, 2021, through April 15, 2022, 3 months before (preintervention) and after (postintervention) pharmacists assumed the responsibility for reviewing ED urine cultures from the nursing staff. For each urine culture, a pharmacist conducted a patient chart review and determined whether an intervention was required. If action was required, the pharmacist provided a recommendation to an ED provider and subsequently implemented the agreed on action. Primary study outcomes included (1) the number of discontinued antibiotics when there was no bacterial infection cultured and (2) when changing antibiotics on the basis of culture results, whether the antibiotic chosen matched current guidelines. Primary postintervention outcomes were compared with preintervention ones using the Fisher exact tests. ResultsPharmacist review in the postintervention period led to a statistically significant higher number of discontinued antibiotics than in the preintervention period (20/65 vs. 0/71, P < 0.001). The antibiotics chosen when altering therapy on the basis of culture results did not differ statistically significant between the pre- and postintervention periods (P > 0.999). ConclusionPharmacist review of urine cultures in a rural ED can improve antimicrobial stewardship outcomes by decreasing unnecessary antibiotic use for the treatment of UTIs.

Managing innovation: a qualitative study on the implementation of telehealth services in rural emergency departments

BackgroundTelehealth studies have highlighted the positive benefits of having the service in rural areas. However, there is evidence of limited adoption and utilization. Our objective was to evaluate this gap by exploring U.S. healthcare systems’ experience in implementing telehealth services in rural hospital emergency departments (TeleED) and by analyzing factors influencing its implementation and sustainability.MethodsWe conducted semi-structured interviews with 18 key informants from six U.S. healthcare systems (hub sites) that provided TeleED services to 65 rural emergency departments (spoke sites). All used synchronous high-definition video to provide the service. We applied an inductive qualitative analysis approach to identify relevant quotes and themes related to TeleED service uptake facilitators and barriers.ResultsWe identified three stages of implementation: 1) the start-up stage; 2) the utilization stage; and 3) the sustainment stage. At each stage, we identified emerging factors that can facilitate or impede the process. We categorized these factors into eight domains: 1) strategies; 2) capability; 3) relationships; 4) financials; 5) protocols; 6) environment; 7) service characteristics; and 8) accountability.ConclusionsThe implementation of healthcare innovation can be influenced by multiple factors. Our study contributes to the field by highlighting key factors and domains that play roles in specific stages of telehealth operation in rural hospitals. By appreciating and responding to these domains, healthcare systems may achieve more predictable and favorable implementation outcomes. Moreover, we recommend strategies to motivate the diffusion of promising innovations such as telehealth.

Seizures and emergency department: characteristics and factors of repeat adult attendees.

To identify risk factors and characteristics for the repeated attendance at an emergency department (ED) following a seizure. A retrospective cohort study was conducted using non-identifiable data of individuals attending ED at least twice between 2015 and 2018, following a seizure. Data were drawn from the patient administration system of an English rural medium-sized teaching district general hospital emergency department (ED), serving a population of 566,000 people. It was analysed for bio-psycho-social features associated with repeat attendances. Of 3522 seizure-related attendances in the four years, 450 people were identified to be repeaters attending on two or more occasions (range 2-12). Just over a quarter (27%) were 18-29years old. Higher likelihood of re-attendance was associated with social deprivation and no fixed abode. Mental illness was a significant co-morbidity influencing repeat attendances. Nearly half (47%) had no recorded anti-seizure medication (ASM). Three fifth (60%) were on general medication and a quarter (25%) on psychotropics. Nearly a quarter (22%) had alcohol and recreational drug concerns. Just over a quarter (28%) had no previous epilepsy diagnosis. Nearly a fifth (n = 85, 19%) died during the study period. People who present repeatedly with seizures at ED are at significant risk of death over a four-year period and require pro-active clinical follow-up. People who are homeless or from socially deprived areas are over-represented in this group, as are those with alcohol problems, co-morbid mental health conditions and compliance issues. This suggests enhanced targeted intervention for this cohort is needed.

Suicide-related crisis presentations to a rural emergency department: A retrospective cohort study.

The study sought to investigate the profile and characteristics of suicide-related crisis presentations and factors associated with repeat presentations to a rural hospital Emergency Department (ED). This retrospective cohort study examined suicide-related crisis presentation data from a rural ED for the years 2008-2018 inclusive. Descriptive statistical analyses included demographic characteristics and trends over time. Factors associated with increased likelihood to re-present to the ED for suicide-related crisis were identified using Odds Ratio analyses. First Nations People, adolescents and young adults were at increased risk of presentation. Suicidal crisis presentations had increased well beyond that which might be accorded to the catchment's population increase and almost a third of presentations involved individuals re-presenting in suicide-related crisis. Repeat presentation was positively associated with younger age, less acute triage category, discharge to the community and leaving the ED before/during treatment. This study illustrates the importance of flagging, follow-up and support of rural repeat presenters to reduce further suicidal behaviours and presentation. Findings support the need for culturally safe and appropriate interventions and follow-up services. It is recommended to extend approach this to non-ED settings.

Elderly patients presenting to a rural hospital emergency department in inland Croatia – A retrospective study

BackgroundEmergency departments are faced with a high influx of patients presenting for various complaints. The aim of the present study was to assess the basic characteristics of elderly patients presenting to a rural hospital emergency department in inland Croatia in 2017. MethodsRetrospective data collected from the Hospital Information System and by analysis of medical records on patients presenting to emergency department in 2017 were used in the study. ResultsStudy results indicated that a lower proportion of elderly individuals aged 65–74 were hospitalized following emergency department workup. A statistically significantly higher proportion of patients older than 74 years was presented to ED due to various discomforts and diseases (ICD-10 group I; χ2 = 324.85; p < 0.01) than due to cardiorespiratory diseases and acute abdomen (χ2 = 285.04; p < 0.01). ConclusionOur findings highlight the need for a complex approach in care for elderly people, given that they are a fragile population with multiple comorbidities, chronic diseases, atypical symptoms, and often with cognitive and functional impairments.

Rural Availability of Sexual Assault Nurse Examiners (SANEs).

Sexual assault care provided by sexual assault nurse examiners (SANEs) is associated with improved health and prosecutorial outcomes. Upon completion of SANE training, nurses can demonstrate their experience and expertise by obtaining SANE certification. Availability of nurses with SANE training or certification is often limited in rural areas, and no studies of rural certified SANEs exist. The purpose of this study is to describe rural SANE availability. We analyze both county-level and hospital-level data to comprehensively examine SANE availability. We first describe the geographic distribution of certified SANEs across rural and nonrural (ie, urban or suburban) Pennsylvania counties. We then analyze hospital-level data from semistructured interviews with rural hospital emergency department administrators using qualitative content analysis. We identified 49 certified SANEs across Pennsylvania, with 24.5% (n = 12) located in 8 (16.7%) of Pennsylvania's 48 rural counties. The remaining 37 certified SANEs (75.5%) were located in 13 (68.4%) of Pennsylvania's 19 nonrural counties. Interview data were collected from 63.9% of all eligible rural Pennsylvania hospitals (n = 63) and show that 72.5% (n = 29) have SANEs. Of these, 20.7% (n = 6) have any certified SANE availability. A minority of hospitals (42.5%; n = 17) have continuous SANE coverage. Very few SANEs in rural Pennsylvania have certification, suggesting barriers to certification may exist for rural SANEs. Though a majority of hospitals have SANEs, availability of SANEs was limited by inconsistent coverage. A lack of certified SANEs and inconsistent SANE coverage may place rural sexual assault victims at risk of receiving lower quality sexual assault care.

Deploying an Electronic Clinical Decision Support Tool for Diagnosis and Treatment of Pneumonia Into Rural and Critical Access Hospitals: Utilization, Effect on Processes of Care, and Clinician Satisfaction.

Electronic clinical decision support (CDS) for treatment of community-acquired pneumonia (ePNa) is associated with improved guideline adherence and decreased mortality. How rural providers respond to CDS developed for urban hospitals could shed light on extending CDS to resource-limited settings. ePNa was deployed into 10 rural and critical access hospital emergency departments (EDs) in Utah and Idaho in 2018. We reviewed pneumonia cases identified through ICD-10 codes after local deployment to measure ePNa utilization and guideline adherence. ED providers were surveyed to assess quantitative and qualitative aspects of satisfaction. ePNa was used in 109/301 patients with pneumonia (36%, range 0%-67% across hospitals) and was associated with appropriate antibiotic selection (93% vs 65%, P < .001). Fifty percent of survey recipients responded, 87% were physicians, 87% were men, and the median ED experience was 10 years. Mean satisfaction with ePNa was 3.3 (range 1.7-4.8) on a 5-point Likert scale. Providers with a favorable opinion of ePNa were more likely to favor implementation of additional CDS (P = .005). Satisfaction was not associated with provider type, age, years of experience or experience with ePNa. Ninety percent of respondents provided qualitative feedback. The most common theme in high and low utilization hospitals was concern about usability. Compared to high utilization hospitals, low utilization hospitals more frequently identified concerns about adaptation for local needs. ePNa deployment to rural and critical access EDs was moderately successful and associated with improved antibiotic use. Concerns about usability and adapting ePNa for local use predominated the qualitative feedback.

Local Capacity for Emergency Births in Rural Hospitals Without Obstetrics Services.

Rural hospitals are closing obstetric units, and limited information is available about local emergency obstetric preparedness and capacity in rural communities where hospitals do not routinely provide this care. To describe emergency obstetric capacity at rural US hospitals that do not routinely offer childbirth services. Data from the 2018 American Hospital Association Annual Survey were used to identify a random sample of rural hospitals that did not offer obstetric services. A survey was developed based on World Health Organization criteria for obstetric emergencies. With data collected from 69 rural hospital emergency departments (48% response rate), we analyzed local capacity to support childbirth. Most responding hospitals (65%) were located 30 or more miles away from a hospital with obstetric services. Some reported having emergency room births in the past year (28%), an unanticipated adverse birth outcome (32%), and/or a delay in urgent transport for a pregnant patient (22%). More than 90% of responding hospitals had capacity for blood transfusion, intravenous antibiotics or anticonvulsants, and basic neonatal resuscitation. However, less than one-fifth had capacity to perform surgery (16%), remove retained products of delivery (17%), or had a policy for emergency cesarean (18%). Almost all respondents (80%) reported the need for additional training or resources to handle emergency obstetric situations. Many rural hospitals do not have basic capacity to provide emergency obstetric services. Programs and policies to improve this may focus on surgical care, clinician and staff training, transportation, and coordination with nearby hospitals that provide obstetric services.

What presents to a rural district emergency department: A case mix.

BackgroundThere is little information available on the range of conditions presenting to generalist run rural district hospital emergency departments (EDs) which are the first point of acute care for many South Africans.AimThis study aims to assess the range of acute presentations as well as the types of procedures required by patients in a rural district hospital context.SettingZithulele is a 147-bed district hospital in rural Eastern Cape.MethodsThis is a cross-sectional study assessing all patients presenting to the Zithulele hospital emergency department from 01 October 2015 to 31 December 2015. Data collected included the triage acuity using the South African Triage Scale system, patient demographics, diagnosis, outcome and procedures performed. Diagnoses were coded retrospectively according to the international statistical classification of diseases and related health problems version 10 (ICD 10).ResultsOf the 4 002 patients presenting to the ED during the study period, 2% were triaged as emergencies and 45% as non-urgent. The most common diagnostic categories were injuries, infections and respiratory illnesses respectively. Diagnoses from all broad categories of the ICD-10 were represented. 67% of patients required no procedure. Diagnostic procedures (n = 877) were more prevalent than therapeutic procedures (n = 377). Only 2.4% of patients were transferred to a referral centre acutely.ConclusionPatients with conditions from all categories of the ICD-10 present for management at rural district hospitals. Healthcare professionals working in this setting need to independently diagnose and manage a wide range of ED presentations and execute an assortment of procedures.

Reduction of paediatric head CT utilisation at a rural general hospital emergency department

BackgroundBlunt head injury is a common pediatric injury and often evaluated in general emergency departments. It estimated that 50% of children will undergo a head computed tomography (CT), often unnecessarily...

Facilitators and Barriers to Care in Rural Emergency Departments in Alberta for Patients on Peritoneal Dialysis (PD): An Interpretive Descriptive Study.

Background:Home dialysis offers many advantages to patients, but they require support to manage a home-based therapy such as peritoneal dialysis (PD). A rural emergency department provides an important safety net for patients requiring medical care, including managing complications of PD, such as peritonitis. Patients living in northern Alberta are spread out geographically and can be far from a PD training center, yet anecdotally, many rural sites do not provide care for these patients.Objective:Our aim was to identify the facilitators and barriers to nursing care in rural emergency departments in northern Alberta for patients receiving PD.Design:A qualitative interpretive descriptive approach was used.Setting:Rural emergency departments across northern Alberta.Participants:Purposeful sampling was used to seek participants from 1 of 4 rural acute care hospital emergency departments in northern Alberta. Six registered nurses and 1 licensed practical nurse agreed to participate in the study. They ranged in experience from 2 to 18 years. Two of the participants were unit managers, 2 were clinical nurse educators (CNEs), and the other 3 were staff nurses with 1 of them in a leadership position.Methods:Individual semistructured interview were conducted over the telephone. The interview guide was developed based on a review of the literature. Interviews continued until no new information was obtained, that is, data were saturated. Interviews were audio recorded and transcribed verbatim. Field notes were recorded. A constant comparative approach was used for analysis. The coding process was both deductive (drawing from the literature) and inductive.Results:Seven participants were interviewed, and there were 4 main themes and 1 subtheme that emerged from the analysis: education (along with the subtheme of resources) was seen as both facilitators and barriers; patient/family ability to perform PD; infrequent exposure; and physician supports. Continuing education about PD was a facilitator, and the lack of education was a barrier to provision of PD care. Similarly, availability of resource materials about PD and access to a CNE were facilitators, while lack of these resources was a barrier to offering PD care. As PD was not always seen regularly, infrequent exposure was a barrier to offering PD care. Lack of physician supports, both from the locum physicians who were sometimes reluctant to care for these patients and the delays in reaching nephrologists were barriers.Limitations:The findings represent the perceptions of the emergency department nurses who participated. These perceptions may differ from those of nurses who work in other regions of the country. Furthermore, most participants were in a leadership role, and it may be that their perspectives differ from those of front-line nurses.Conclusions:The findings from our study highlight the need for availability of education and resource materials/persons to care for these patients. There is also a need for greater physician support from both local physicians as well as nephrologists to offer high-quality PD care.Trial registration:Not applicable. This study is not a clinical trial. It did not involve prospective assignment of participants to a treatment group.

A case-study of the experiences of junior medical officers in the emergency departments of a metropolitan hospital and rural hospital.

Increased exposure to post-graduate rural medical training is associated with increased likelihood of future rural practice. Training rotations in rural emergency departments provide a possible avenue for such exposure, but have been under-investigated. This study aimed to compare junior medical officers' emergency department experiences in a metropolitan and a rural hospital to inform rural health workforce initiatives. Mixed-method case-study design. Two 10-week periods in the respective emergency departments. Four junior medical officers at the rural site and 22 junior medical officers at the metropolitan hospital. Caseloads extracted from electronic medical records and training experience. Data were collected over 142days. The average number of patients seen per day, per junior medical officer, was significantly higher at the rural hospital emergency department (7.2 patients per day) in comparison with the metropolitan hospital (4.3 patients per day). Junior medical officers at the rural hospital saw relatively more lower acuity patients. The seven junior medical officers who were interviewed provided consistently positive responses regarding their training experiences in both locations. This was particularly evident in the rural hospital and was attributed to one-on-one supervision. Most junior medical officers agreed that their expectations for support and learning opportunities were met and/or exceeded. However, junior medical officers reported feeling more supported at the rural hospital due to direct contact and communication with senior medical officers. Placement in a smaller hospital emergency department did not disadvantage the junior medical officers' training in this case-study and provided a positive rural training experience. These findings support workforce policies which encourage rural hospital emergency department training.

Telemedicine is associated with rapid transfer and fewer involuntary holds among patients presenting with suicidal ideation in rural hospitals: a propensity matched cohort study

ObjectiveThe purpose of this study was to evaluate the impact of telemedicine in clinical management and patient outcomes of patients presenting to rural critical access hospital emergency departments (EDs) with...

Factors associated with availability of anticoagulation reversal agents in rural and community emergency departments.

Results of a study of anticoagulation reversal agent availability in rural and community hospital emergency departments (EDs) are reported. A cross-sectional telephone survey was conducted to test the hypothesis that anticoagulation reversal agents are not commonly stocked in low-volume EDs. In phase 1 of the study, a physician, pharmacist, or nurse manager at a sample of EDs in 1 state was surveyed to characterize anticoagulation reversal agent availability and the presence or absence of reversal protocols; in phase 2, follow-up qualitative interviews were conducted with hospital pharmacists selected by purposive sampling to identify barriers to availability. Among the 103 EDs represented in the survey, 87 (84%) stocked fresh frozen plasma, 14 (14%) stocked 4-factor prothrombin complex concentrate (4F-PCC), and 2 (2%) stocked activated 4F-PCC. Forty-one EDs (40%) had a warfarin reversal protocol, but only 2 (2%) EDs had a protocol for direct oral anticoagulant reversal. ED volume and neurology coverage were significantly associated with reversal agent availability (p = 0.014) and warfarin protocol availability (p < 0.001). Identified factors contributing to reversal agent nonavailability were product cost, lack of knowledge of drug availability, and concerns about shelf life. An investigation of rural and community hospitals in 1 state revealed that the institutions rarely have specialized anticoagulation reversal drugs available. Cost and infrequency of utilization were 2 commonly cited reasons for reversal agent nonavailability.

An analysis of injury patterns of abdominal trauma in patients attending surgical emergency department of rural hospital, Karnataka, India

Background: Globally, abdominal trauma is a major public health problem irrespective of socioeconomic levels. Severe blood loss and infection are the serious complication of any abdominal trauma. A detailed assessment for early identification and prompt management is required to reduce the mortality and morbidity in any abdominal trauma. Hence this study was designed to assess the incidence and patterns of abdominal injuries in trauma patients.Methods: It was assorted and identified the incidence and sub type of abdominal injuries and associated trauma, and identified variables related to morbidity and mortality.Results: A total of 150 abdominal trauma cases were analyzed; 103 patients with blunt abdominal trauma and 47 with penetrating. The most frequent type of abdominal trauma was blunt trauma; its most common cause was motor vehicle accident. Most abdominal trauma patients presented with other injuries, especially patients with blunt abdominal trauma. Mortality was higher among penetrating abdominal trauma patients.Conclusions: Type of abdominal trauma, associated injuries, and Revised Trauma Score are independent risk factors for mortality in abdominal trauma patients.

The positive impact of a trauma whiteboard on team performance in a small rural hospital and multiple purpose health service emergency department

The positive impact of a trauma whiteboard on team performance in a small rural hospital and multiple purpose health service emergency department

Balancing safety and harm for older adults with dementia in rural emergency departments: healthcare professionals' perspectives.

The emergency department (ED) is a potentially harmful environment for older adults with dementia, and rural EDs face unique challenges in providing care to this population. The purpose of this study was to understand safety and harm in rural ED transitional care for community dwelling older adults with dementia from the perspective of healthcare professionals (HCPs). An interpretive, descriptive exploratory design from a social ecological perspective was used. Using purposive and snowball sampling, HCPs were recruited from two rural hospital EDs in two Canadian provinces. Data collection involved participant interviews using a semi-structured interview guide. Audio-recorded interviews were transcribed, transcripts coded, and themes identified using constant comparative analysis with thematic coding. A total of 12 HCPs, seven from one province and five from the other, participated in the study. HCPs worked directly in the ED or consulted in the ED from hospital-based social work, rehabilitation and community liaison services. Three themes were identified: physical environment (space, design and equipment), work environment (pressure to perform) and practice environment (family, knowledge and processes). A conceptual model was developed to illustrate how HCPs worked to balance safety and harm for older patients with dementia within a milieu created by the overlapping and synergistically interacting environments. HCPs in rural EDs working at the interface of hospital and community constantly attempt to balance promoting safety and avoiding harm for older adults with dementia. Participants perceived safety broadly, understanding that the consequences of the milieu were created through an interaction between physical, work and practice environments. These consequences related to the physical, cognitive and emotional wellbeing of older adults with dementia and their caregivers. Within the practice environment, participants identified a 'rural advantage' that was tied to their knowledge of community and the people with dementia and their caregivers who sought care in the participating EDs. However, familiarity can be a double-edged sword and to minimize potential harm healthcare professionals must seek input from caregivers regarding altered functional status, and policies to change triage to include gerontological knowledge and create elder-friendly rural ED environments are needed.