Our ER rarely sends patients in a direct admit status. We are a medium sized semi-rural area hospital. I say semi rural because we are in a mid-sized city, have approx 200 bed inpt capacity, but we serve a HUGE rural area including very rural parts of a neighboring state. We have a lot of VERY small RURAL hospitals who send their patients to our ER for surgical consult because they have no OR. But we are not recognized as a trauma hospital, though we take trauma, stabilize as best as we can, and ship it out. Most times we ship to the teaching hospital an hour away, to their ER. That way they can evaluate and decide on their diagnosis, without having to deal with their specialists in the middle of the night. Their chopper comes and picks the pts up, or if the chopper won't fly due to weather, we ship accross the mountain by private ambulance. We've always had a great relationship with their ER, which is rated among the top 100 (maybe even higher? not sure) ERs in the nation. I disagree with the poster who said be careful about sneaking a pt in an ER to ER transfer. As long as you don't show up with a critical pt unannounced, I think ER to ER transfers are great, and we do it frequently. In our rural area, there are tons of terrible MVCs, ATV accidents, farm accidents, freak accidents, you name it. In two years, I have seen more nasty accidents (and domestic arguments gone haywire) then I ever would have guessed. High risk OB stuff goes over the mountain without a hitch as well.