Since its enactment in 1986, the Emergency Medical Treatment and Active Labor Act (EMTALA) has served as a cornerstone of patient rights. Designed as an antidiscrimination statute, EMTALA ensures that individuals presenting to the emergency department (ED) receive equal access to screening and stabilization, regardless of their insurance status, background, or ability to pay.
Yet nearly 40 years later, compliance remains a pressing challenge. Each year, approximately 4% of hospitals are cited by the Centers for Medicare & Medicaid Services (CMS) for violations, underscoring that EMTALA obligations are not only legal requirements, but also persistent patient safety issues.
Why EMTALA Still Matters Today
Healthcare delivery has grown more complex since EMTALA’s passage. Today’s challenges—including hospital capacity shortages, access barriers, workforce strain, and the evolving legal landscape surrounding reproductive health—intensify the difficulty of meeting EMTALA standards.
One particularly vulnerable area is obstetric emergencies, which have historically been a leading source of EMTALA violations. Reviews of settlements between 2002 and 2018 found that:
- 1 in 6 EMTALA settlements involved obstetric emergencies
- 1 in 5 of those cases involved a pregnant minor
These cases highlight potential knowledge and process gaps in how clinicians apply EMTALA requirements in urgent and sensitive situations.
EMTALA’s Core Requirements
At its heart, EMTALA mandates two obligations for hospitals with dedicated EDs:
- Provide a Medical Screening Examination (MSE)—
Every patient must receive an appropriate MSE to determine whether an emergency medical condition (EMC) exists; for pregnant patients, this includes assessment of both mother and fetus - Provide Stabilizing Treatment or Appropriate Transfer—
If an EMC is identified, the hospital must stabilize the patient within its capability and capacity—or arrange a transfer to a facility that can provide the needed level of care
For obstetric patients, CMS explicitly considers labor and delivery units to be dedicated EDs, meaning these requirements apply equally to labor triage and delivery areas.
Special Considerations for Obstetric Emergencies
When pregnant patients present to the ED or labor unit, EMTALA obligations extend to both the mother and fetus. The MSE should include:
- Contraction assessment (regularity, frequency, and duration)
- Fetal heart tones and monitoring
- Fetal position and station
- Cervical dilation and effacement
- Status of membrane rupture
- Evaluation for complications such as preeclampsia or placental abruption
If a patient is in labor and meets EMC criteria, “stabilization” under EMTALA means delivery of both the baby and placenta. Until then, transfer decisions carry high risk and require detailed documentation.
Requirements for Patient Transfer
When a hospital cannot stabilize a patient due to limitations in capacity or capability, transfer may be necessary. EMTALA permits transfer in two main circumstances:
- Medical necessity—The benefits of care at the receiving hospital outweigh the risks
- Patient request—The patient (or representative) requests transfer in writing after being informed of risks and the hospital’s obligations
In both cases, several conditions must be met:
- Transfer certification by the physician, stating risks and benefits
- Acceptance from the receiving facility prior to transfer
- Use of qualified personnel and medically appropriate transportation
- Transmission of complete medical records, including nursing documentation
Failure to meet these requirements is a frequent source of citations.
The Role of Interprofessional Communication
Safe transfer depends on effective communication across disciplines and institutions. Physicians must reassess patients immediately before transfer and document their evaluation. Nurses must also perform reassessments, provide detailed handoffs, and ensure all documentation accompanies the patient.
Best practices include:
- Checklists outlining required documentation and handoff items
- Direct nurse-to-nurse handoff communication between facilities
- Standardized interhospital transfer protocols to reduce variability and risk
Practice Pearls for Clinicians
- Document thoroughly—Transfer certifications cannot be implied from the medical record; they must be explicit, timed, dated, and signed
- Engage patients—Inform patients or representatives of risks and benefits of transfer, and document consent whenever possible
- Prepare for transport—Partner with ambulance services that can provide trained personnel and appropriate life-support equipment
- Focus on fetal assessment—Always evaluate and document fetal status when pregnant patients present to the ED
- Strengthen protocols—Develop and rehearse interhospital transfer procedures, particularly for high-risk obstetric cases
Moving Forward
EMTALA compliance is not just a regulatory requirement—it’s a patient safety imperative. The statute is designed to ensure that every patient, regardless of circumstance, receives equitable and safe emergency care. By reinforcing clinician education, implementing checklists, standardizing transfer protocols, and prioritizing interprofessional communication, healthcare organizations can reduce EMTALA-related risk and protect both patients and providers.
Bottom line: EMTALA has stood for nearly 4 decades as a safeguard of equity in emergency medicine. But in today’s evolving healthcare landscape, compliance requires vigilance, teamwork, and a system-level commitment to safe, patient-centered care.
Want to discuss your specific risk challenges? Contact Catherine Mullaney, MHA at cbretz@med-iq.com.
