{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,18]],"date-time":"2026-09-18T18:11:12Z","timestamp":1789755072108,"version":"4.0.1"},"reference-count":40,"publisher":"Public Library of Science (PLoS)","issue":"9","license":[{"start":{"date-parts":[[2026,9,18]],"date-time":"2026-09-18T00:00:00Z","timestamp":1789689600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Fonds de recherche du Qu\u00e9bec \u2013 Sant\u00e9","award":["22481"],"award-info":[{"award-number":["22481"]}],"id":[{"id":"https:\/\/ror.org\/02eqrsj93","id-type":"ROR","asserted-by":"crossref"}]},{"name":"Fonds de recherche du Qu\u00e9bec \u2013 Sant\u00e9","award":["32825"],"award-info":[{"award-number":["32825"]}],"id":[{"id":"https:\/\/ror.org\/02eqrsj93","id-type":"ROR","asserted-by":"crossref"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Rural emergency departments (EDs) are critical to ensuring equitable access to acute care, yet face persistent systemic challenges. In Qu\u00e9bec, Canada, reforms to healthcare governance, funding and resource allocation, and service delivery have transformed rural ED operations. This study aimed to document characteristics, challenges, and improvement priorities for all rural EDs in the province.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A participatory mixed-methods design was used. 26 rural EDs in Qu\u00e9bec were included. Data sources comprised administrative statistics, structured site surveys, individual stakeholder semi structured interviews, and a validation survey of identified local champions. Analyses comprised a triangulation of the quantitative and qualitative data using transversal thematic analysis to determine common issues. Potential solutions identified were validated through stakeholder questionnaires. The study was reported in accordance with the COREQ reporting guideline.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Most respondents were women (64%) and professionals with more than 5 years of experience. Four main themes were identified: governance, healthcare organization, access to resources, and professional practice. Governance challenges included reduced local autonomy, administrative complexity, and budgeting models poorly adapted to rural realities. Participants emphasized the need for standardized but locally flexible administrative processes, regional emergency service managers, and rural-sensitive performance metrics. Organizational barriers included geographic isolation, limited access to primary care, and difficulties with interfacility transfers due to referral-center capacity and ambulance shortages. Resource constraints centered on shortages of human resources, diagnostic services and specialty coverage, especially anesthesia, obstetrics, and psychiatry. Professional practice was shaped by the need to maintain broad competencies in low-volume contexts, while contending with professional isolation and proximity to patients. Local champions prioritized expanding telemedicine, strengthening prehospital services, enhancing continuing education, and implementing tailored recruitment strategies.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>This study provides the first province-wide documentation of characteristics, challenges, and improvement priorities for all rural EDs. Findings highlight the need for systemic reforms that restore local decision-making authority, strengthen transfer and prehospital capacity, expand telehealth and specialty access, and support professional development. These results provide a foundation for evidence-based policies and actions to sustain equitable emergency care in rural regions.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0342965","type":"journal-article","created":{"date-parts":[[2026,9,18]],"date-time":"2026-09-18T17:45:57Z","timestamp":1789753557000},"page":"e0342965","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Rural Emergency 360\u00b0: A mixed-methods analysis of barriers and priorities for equitable emergency care in Qu\u00e9bec"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0063-6354","authenticated-orcid":true,"given":"Richard","family":"Fleet","sequence":"first","affiliation":[{"name":"Centre int\u00e9gr\u00e9 de sant\u00e9 et de services sociaux de Chaudi\u00e8re-Appalaches","place":["L\u00e9vis, Quebec, Canada"],"department":["Centre de recherche int\u00e9gr\u00e9e pour un syst\u00e8me apprenant en sant\u00e9 et services sociaux"]},{"name":"VITAM-Centre de recherche en sant\u00e9 durable","place":["Qu\u00e9bec, Quebec, Canada"]},{"name":"Universit\u00e9 Laval","place":["Qu\u00e9bec, Quebec, Canada"],"department":["Department of Family Medicine and Emergency Medicine"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Catherine","family":"Turgeon-Pelchat","sequence":"additional","affiliation":[{"name":"CISSS du Bas-Saint-Laurent","place":["Rimouski, Quebec, Canada"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fatoumata","family":"Korika Tounkara","sequence":"additional","affiliation":[{"name":"Living Lab Charlevoix - Vitam Research Centre","place":["Qu\u00e9bec, Quebec, Canada"],"department":["Hub d\u2019innovation en m\u00e9decine rurale"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gilles","family":"Dupuis","sequence":"additional","affiliation":[{"name":"UQAM","place":["Montr\u00e9al, Quebec, Canada"],"department":["Department of Psychology"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jean-Paul","family":"Fortin","sequence":"additional","affiliation":[{"name":"VITAM-Centre de recherche en sant\u00e9 durable","place":["Qu\u00e9bec, Quebec, Canada"]},{"name":"Universit\u00e9 Laval","place":["Qu\u00e9bec, Quebec, Canada"],"department":["Facult\u00e9 de m\u00e9decine"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jocelyn","family":"Gravel","sequence":"additional","affiliation":[{"name":"Universit\u00e9 de Montr\u00e9al","place":["Montr\u00e9al, Quebec, Canada"],"department":["Centre Hospitalier Universitaire Sainte-Justine"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mathieu","family":"Ouimet","sequence":"additional","affiliation":[{"name":"Universit\u00e9 Laval","place":["Qu\u00e9bec, Quebec, Canada"],"department":["D\u00e9partement de science politique"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julie","family":"Th\u00e9berge","sequence":"additional","affiliation":[{"name":"HUPR-Centre de recherche sur le potentiel humain","place":["Montr\u00e9al, Quebec, Canada"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"France","family":"L\u00e9gar\u00e9","sequence":"additional","affiliation":[{"name":"Universit\u00e9 Laval","place":["Qu\u00e9bec, Quebec, Canada"],"department":["D\u00e9partement de m\u00e9decine familiale et de m\u00e9decine d\u2019urgence"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5461-7693","authenticated-orcid":true,"given":"Hassane","family":"Alami","sequence":"additional","affiliation":[{"name":"School of Public Health & Center for Public Health Research of the University of Montreal","place":["Montreal, Quebec, Canada"],"department":["Department of Health Management, Evaluation and Policy"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,9,18]]},"reference":[{"key":"pone.0342965.ref001","unstructured":"Government of Canada PS and PC. 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