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A disparity in access to health care exists between rural and urban areas. Although 21% of children in the United States live in rural areas, only 3% of pediatric intensivists practice in rural areas. In an attempt to address this issue, we implemented a program of pediatric critical care telemedicine consultations in rural emergency departments (EDs) and report our results.A prospective evaluation of pediatric critical care consultations in rural EDs was undertaken March 2006 through March 2008. A referral area with a population of 1,000,000 in 19 rural counties in Vermont and upstate New York comprised the study area.Sixty-three telemedicine consultations were performed in 10 rural EDs. The average number of consultations was 6.3 per site (range 2–17). Minor technical issues were identified in 18 consultations (29%). There were 12 primary diagnoses. Telemedicine was used to supervise the critical care transport team on 25 occasions (40%). Consulting intensivists made 236 specific recommendations. Consulting intensivists thought that telemedicine consultations improved patient care 89% of the time, were superior to telephone consultations 91% of the time, and provided good to very good provider-to-provider communications 98% of the time. Referring providers reported that telemedicine consultations improved patient care 88% of the time, were superior to telephone consultations 55% of the time, and provided good to very good communications 94% of the time.With telemedicine, it is feasible to provide urgent subspecialty critical care for children in underserved rural EDs, improve patient care, and provide a high degree of provider satisfaction. Pediatric critical care telemedicine may help to address the disparities in the access to and the outcome of medical care between rural and urban areas.