BACKGROUND: In recent years, rural hospitals have expanded their scope of specialized services, which has led to the development and staffing of rural intensive care units (ICUs). There is little information about the breadth, quality or outcomes of these services. This is particularly true for specialized ICU services such as mechanical ventilation, where little, if any, information exists specifically for rural hospitals. The long-term objectives of this project were to evaluate the quality of medical care provided to mechanically ventilated patients in rural ICUs and to improve patient care through an educational intervention. This paper reports baseline data on patient and hospital characteristics for both rural and rural referral hospitals. RESULTS: Twenty Iowa hospitals were evaluated. Data collected on 224 patients demonstrated a mean age of 70 years and a mean ICU admission Acute Physiology and Chronic Health Evaluation (APACHE) II score of 22, with an associated 36% mortality. Mean length of ICU stay was 10 days, with 7.7 ventilated days. Significant differences were found in both institutional and patient variables between rural referral hospitals and rural hospitals with more limited resources. A subgroup of patients with diagnoses associated with complex ventilation had higher mortality rates than patients without these conditions. Patients who developed nosocomial events had longer mean ventilator and ICU days than patients without nosocomial events. This study also found ICU practices that frequently fell outside the guidelines recommended by a task force describing minimum standards of care for critically ill patients with acute respiratory failure on mechanical ventilation. CONCLUSIONS: Despite distinct differences in the available resources between rural referral and rural hospitals, overall mortality rates of ventilated patients are similar. Considering the higher mortality rates observed in patients with complicated medical conditions requiring complex ventilation management, the data may suggest that this subgroup could benefit from treatment at a tertiary center with greater resources and technology.