108 Characteristics of Emergency Medical Treatment and Labor Act Citations and Their Association With Patient Death

Study Objectives

The Emergency Medical Treatment and Labor Act (EMTALA) was enacted in 1968 in response to reports of inadequate, delayed, or denied treatments of patients due to their insurance status, or lack thereof. EMTALA establishes a duty for hospitals to evaluate all patients who present to the emergency department by providing a medical screening examination as well as stabilizing treatment if an emergent condition is identified, and transfer if patient had an emergent medical condition requiring specialized stabilizing services unavailable at the initial hospital (eg neurosurgery for an epidural hematoma). The Centers for Medicare & Medicaid Services (CMS) is responsible for EMTALA enforcement. Prior work demonstrated that EMTALA violations are relatively common. However, patient-level outcomes from EMTALA citation events have not been previously reported. The objective of this study was to identify and describe the incidence, characteristics of, and trends in EMTALA citation events involving patient deaths.


This observational study examined the trends in the characteristics of EMTALA citation events associated with patient death. Descriptions of all EMTALA citation events from January to September of 2021 were obtained from CMS. The data set included facility location and deficiency type(s) identified in the EMTALA citation along with a free-text summary describing findings of the investigation including descriptions of clinical cases, and typically outcomes. EMTALA citation event summaries were systematically reviewed for references to patient death. When deaths were identified, the location cause, and circumstances of death were systematically extracted and coded. The occurrence of deaths and non-deaths were analyzed against characteristics such as region, and deficiency tag to identify significant trends.


Of 115 EMTALA citation events during the 9-month study period, 12 (10.4%) involved patients who died. Among the 12 involving patient deaths, 7 (58%) were cited for deficiencies related to EMTALA policies and procedures, 6 (50) for failure to provide appropriate medical screening exam, and 4 (33%) for failing to provide stabilizing services, and 4(33%) for failing to restrict transfer until stabilized, though proportion of deficiency types did not differ between events associated with deaths and events not associated with deaths. Of citation events associated with deaths, 8 (66%) occurred in CMS Region 4 (AL, FL, GA, KY, MS, NC, SC, TN) compared to 40% of those that did not. Three (24%) of 12 EMTALA citation events associated with death occurred in CMS Region VII (IA,KS,MO,NE) compared with 7% of those that did not (-18.1 p.p. difference, CI -35.1, -1.1). Of note, outcomes for patients for some citation events were not clearly described, and in one case, a patient pending medical clearance for a psychiatric facility wandered off and has yet to be found, suggesting reported numbers may represent an underestimate of citation events involving deaths.


One in ten EMTALA citations events are associated with patient death (10.43%). A substantial proportion of EMTALA citation events involving deaths occur in two CMS regions, which could indicate the need for more education regarding EMTALA compliance in those regions, as well as further investigation into whether these findings reflect regional variation in quality of care or in EMTALA enforcement activities.

No, authors do not have interests to disclose

The full study is available in Annals of Emergency Medicine.