Problem: People in rural and remote New South Wales experience avoidable admissions, limited access to skilled clinicians and commonly travel >400 km to access specialist services within the district and >700 km for tertiary services outside.

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Background: Provision of critical care in rural areas is challenging due to geographic distance, smaller facilities, generalist skill mix and population characteristics. Virtual emergency clinical advisory and transfer service (vCare) is a novel service developed to utilize telehealth to overcome these challenges. We describe patient encounters with vCare from initial referral to destination and survival, and to provide insights into strengths and weaknesses of the service as well as areas for further educational and research opportunities. Methods: This retrospective observational study reviewed all patients using vCare in rural and remote Australia for advice and/or inter-hospital transfer for higher level of care between February and March 2021. Data, extracted from electronic medical records and descriptively analyzed, included patient demographics, clinicians involved, resources utilized, transfer features, escalation of care, post-transfer care and survival. Results: 1,672 critical care patients were supported by vCare, with children (12.5%), adults (50.5%) and older people (36.9%) evenly split between genders. Clinicians mainly referred to vCare for trauma (15.1%), cardiac (16.1%) and gastroenterological (14.8%) presentations. A referral to vCare led to an escalation of invasive intervention, skill and resources for patient care. vCare cameras were used in 19.2% of cases. Overall, 68% (n=1,144) of patients required transfer. Of those, 95% were transferred to major regional hospitals and 12% required secondary transfer to higher acuity hospitals. Of high-urgency referrals, 42.6% did not receive high priority transport. Imaging most requested included CT and MRI scans (37.2%). Admissions were for physician (33.1%) and surgical care (23.3%). The survival rate was 99%. Conclusion: vCare was used by staff in rural and remote facilities to support decision making about delivery of care to patients in a critical condition. Its strengths lie in the provision of timely escalation of care, streamlined patient transfer and assisting patients in accessing care close to home. However, it does not replace the role of clinicians on the ground. Utilization of telehealth tools, such as cameras, was unexpectedly low and other weaknesses included limited high priority transfers, high proportion of secondary transfers and heavy reliance on regional sites for specialty care and imaging.