I dont think that this is the right way to meet up with the needs of small rural hospitals. Of course video conferencing and exchanging medical data can improve finding a diagnosis, but what sense would it make if telemedicine would suggest placing an ECMO in a crashing heart failure patient when there is a) no device around and b) no one with enough experience. 

I do think APP's can provide great are for critical care patients, and I do think telemedicine can be a valuable tool, and a way for rural facilities to access additional expertise, consultation, insight, etc.  I'm not sure telemedicine should have a primary role in critical care however.  As an adjunct, sure.  But to resolve a staffing need, no.  There is no substitute for hands on assessments and instincts,  and especially critical thinking at the bedside.  If facilities are unable to properly staff for areas with patients with critical care needs, then the focus needs to be on setting up relationships with tertiary care facilities, critical care transports, to ensure these patients get to where they need to be for the best care possible.

I think it depends on your definition of "rural" and the proximity of your "rural" community to an urban center (with tertiary care). I live in North Carolina (USA) and our idea of rural is vastly different than experiences shared by colleagues in the Dakotas, Montana, Wyoming, etc. While we (NC) have many "rural" communities, most all of them are one fuel load and a rotor wing flight from a tertiary center. When your closest tertiary center is one or two states away, with huge travel implications for family, and require a fixed wing aeromedical flight from the closest airport to the closest airport, it's all the more important to be creative. APPs and technology are not a certain 100% substitution for the appropriate physician but can certainly fill gaps in service when the distance is significant and the volume/finances simply won't support the staffing, resources, etc. of a tertiary center. I would suggest you look at some of the military medicine experiences involving care being directed from the CONUS to a forward medical unit in Afghanistan relying on technology and at times, the staffing of Medics/Corpsmen.

Clinical Leadership skills training is the key to quality care management in rural and remote areas. NP would be best suited to be utilised as a clinical leader of a multidisciplinary health team and working in partnership with the MD. The issue will be the skill set needed to undertake collaborative care management and transform the team into a partnership. As for Tele-health,  Australia is doing great with it in all aspects for empowering consumer and clinician.

The observations needed to answer this question is the evidence of PA/NPs in ICUs.  In this regard there are at least 10 good (and 2 very good) studies that shows the care/outcome is equivalent to MDs.  So the subsitution factor is in place.  The other is the role in rural health.  If we use the NCHS definition of most rurality and look at those providers occupying rural and critical access hospitals and territorial hospitals (~1100) we see an increasing presence of PA/NPs and a decreasing presence of MD/DO/MBBSs.  No one should deny that an MD is ideal in these situations but if need outstrips desire than employing PA/NPs in these critical roles may be the next best thing - all things considered.  Research on this matter is in short supply.