Trauma and emergency surgical care at rural emergency hospital-eligible facilities: Interstate variation and policy implications for rural health systems.

introductionTimely access to emergency surgical care is a key metric for health system development and performance. To mitigate the risks of rural hospital closures in the United States, the 2021 Consolidated Appropriations Act introduced the rural emergency hospital (REH) designation, which promotes closure of inpatient units in small hospitals in favor of emergency and outpatient services via supplemental funding and reimbursement. We investigated trauma and emergency general surgery volumes at REH-eligible hospitals to evaluate the potential impact of REH designation on trauma and emergency general surgery care.

methodsWe used the 2021 Healthcare Cost and Utilization Project from five geographically diverse states (California, Florida, Iowa, Maryland, and Wisconsin) to select encounters where adult patients were treated for acute injuries or emergency general surgery conditions. We then identified REH-eligible hospitals (critical access hospitals or rural hospitals with <50 inpatient beds), comparing case volumes and patient populations at REH-eligible and -ineligible hospitals.

resultsWe analyzed 2.1 million encounters. Trauma and emergency general surgery encounters at REH-eligible hospitals demonstrated substantial interstate variation, comprising 2% to 37% of statewide hospitalizations and up to 17% of statewide inpatient days, with rural states showing the highest proportions. Compared with ineligible hospitals, REH-eligible hospitals treated a higher proportion of patients who were White (85% vs. 55%), were living in rural areas (79% vs. 8%), and had lower incomes; treated fewer patients operatively (2% vs. 11%); and transferred more patients (5% vs. 3%) (all p  < 0.001).

conclusionHospitals eligible for REH designation contribute substantially to the care of injured and emergency general surgery patients, although this is variable across states. While this policy may preserve emergency services in rural areas, the substantial variation in REH-eligible hospital utilization and the vulnerable populations served necessitate systematic evaluation of impacts on surgical access, transfer protocols, and regional care capacity given the irreversible structural changes inherent in this designation. ( J Trauma Acute Care Surg . 2026;100: 768-776. Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Prognositc and Epidemiologic; Level III.