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Background: The geography of rural Australia poses a myriad of logistical dilemmas, including the provision of timely access to emergency orthopaedic hip fracture surgery. Current guidelines support surgery within 48 h, and delays to transfer to a referral hospital may result in worse outcomes and increase mortality rates. The aim of this study was to examine the effect of transfer delays on the clinical outcomes of hip fractures in a rural setting., Methods: We retrospectively reviewed 265 hip fracture patients who underwent surgical management between 2013 and 2015 at a rural referral hospital. Factors such as age, time to surgery, delay to surgery, preoperative clinical deterioration, preoperative transthoracic echocardiogram, American Society of Anesthesiologists class and 30-day and 1-year mortality rates were examined. Unadjusted odds ratios were calculated for statistically significant primary and secondary outcomes., Results: The mean delay to transfer was 19.9 h. Patients were 6.76 times more likely to undergo surgery within 48 h if they presented to the referral hospital first. Surgery within 48 h was more likely in those who presented to the referral hospital first, had no preoperative transthoracic echocardiogram and did not experience a preoperative clinical deterioration. The 30-day mortality rates were significantly higher in those who had surgery after 48 h or underwent a preoperative clinical deterioration., Conclusion: Increased time to hip fracture surgery was associated with increased mortality rates. Transfer delays from a peripheral hospital had a significant bearing on time to surgery. Early transfer to a referral hospital is recommended., (© 2019 Royal Australasian College of Surgeons.)