(922) Temporal, regional and hospital-type variation in EMTALA violations involving obstetric emergencies, 2018-2023

Objective: The Emergency Medical Treatment and Labor Act (EMTALA) requires hospitals to screen, stabilize, and, if appropriate, transfer patients presenting to emergency departments (EDs) seeking emergency care and/or labor evaluation. EMTALA is enforced by the 10 regional offices of the Centers for Medicare & Medicaid Services (CMS), which may vary in their processes. We aim to describe regional variations in EMTALA enforcement related to obstetric (OB) emergencies in the United States from 2018 to 2023, with attention to temporal variations related to the COVID-19 pandemic.

Study Design: This is a retrospective study of 2837 EMTALA violations from 2018 to March 2023 obtained from CMS, including dates, locations, and hospital types. Inspection text was systematically reviewed for keywords for the involvement of pregnant patients and/or OB emergencies. We compared temporal and regional variations in EMTALA violations involving OB versus non-OB emergencies.

Results: During the study period, 294 (10.4%) violations involved OB emergencies. Rates of clinical deficiencies were 11 percentage points higher in OB violations versus non-OB violations. OB-related violations accounted for 12% of EMTALA-related violations prior to the COVID-19 pandemic versus 8.7% from 2020 to 2021. While violations from 2022 and 2023 are incompletely reported, available data note a continued downtrend to 8.3%. By CMS region, regions 4 (South Atlantic), 9 (Southwest), and 10 (Northwest) contributed to disproportionately more OB-related violations (differences of 2.8, 2.5, and 2.1 percentage points, respectively). Critical Access Hospitals (CMS-designated eligible rural hospitals) account for 20.7% of OB-related violations but only 17.5% of non-OB-related violations in contrast to short-term hospitals with near-identical proportions.

Conclusion: The proportion of EMTALA violations involving OB emergencies decreased over time. Proportions additionally varied by CMS region and hospital type. Recent changes in legislation impacting access to reproductive services may impact future temporal and regional variations in OB-related EMTALA violations.