Key findings of this study are: 1) Telemedicine consultation for emergency department (ED) sepsis care is rare, but a dedicated utilization initiative modestly increased use; 2) A multi-pronged approach of nurse-directed screening, recommended consultation criteria, and real-time hub decision-support were implemented in a large rural ED-based telemedicine network; 3) Appropriately balancing the sensitivity of telemedicine consultation recommendations is critical to limit alarm fatigue and identify patients most likely to benefit.