Environmental Influences on Patient Presentations: Considerations for Research and Evaluation at Mass-Gathering Events.

AIM: This paper discusses the need for consistency in mass-gathering research and evaluation from an environmental reporting perspective. BACKGROUND: Mass gatherings occur frequently throughout the world. Having an understanding of the complexities of mass gatherings is important to inform health services about the possible required health resources. Factors within the environmental, psychosocial, and biomedical domains influence the usage of health services at mass gatherings. A minimum data set (MDS) has been proposed to standardize collection of biomedical data across various mass gatherings, and there is a need for an environmental component. The environmental domain includes factors such as the nature of the event, availability of drugs or alcohol, venue characteristics, and meteorological factors. METHOD: This research used an integrative literature review design. Manuscripts were collected using keyword searches from databases and journal content pages from 2003 through 2018. Data were analyzed and categorized using the existing MDS as a framework. RESULTS: In total, 39 manuscripts were identified that met the inclusion criteria. CONCLUSION: In collecting environmental data from mass gatherings, there must be an agreed-upon MDS. A set of variables can be used to collect de-identified environmental variables for the purpose of making comparisons across societies for mass-gathering events (MGEs).

On the Way Out: An Analysis of Patient Transfers from Four Large-Scale North American Music Festivals Over Two Years.

INTRODUCTION: Music festivals are globally attended events that bring together performers and fans for a defined period of time. These festivals often have on-site medical care to help reduce the impact on local health care systems. Historically, the literature suggests that patient transfers off-site are frequently related to complications of substance use. However, there is a gap in understanding why patients are transferred to hospital when an on-site medical team, capable of providing first aid services blended with a higher level of care (HLC) team, is present. OBJECTIVE: The purpose of this study is to better understand patterns of injuries and illnesses that necessitate transfer when physician-led HLC teams are accessible on-site. METHODS: This is a prospective, descriptive case series analyzing patient encounter documentation from four large-scale, North American, multi-day music festivals. RESULTS/DISCUSSION: On-site medical teams that included HLC team members were present for the duration of each festival, so every team was able to "treat and release" when clinically appropriate. Over the course of the combined 34 event days, there were 10,406 patient encounters resulting in 156 individuals being transferred off-site for assessment, diagnostic testing, and/or treatment. A minority of patients seen were transferred off-site (1.5%). The patient presentation rate (PPR) was 16.5/1,000. The ambulance transfer rate (ATR) was 0.12/1,000 attendees, whereas the total transfer-to-hospital rate (TTHR), when factoring in non-ambulance transport, was 0.25/1,000. In contrast to existing literature on transfers from music festivals, the most common reason for transfer off-site was for musculo-skeletal (MSK) injuries (53.8%) that required imaging. CONCLUSION: The presence of on-site HLC teams impacted the case mix of patients transferred to hospital, and may reduce the number of transfers for intoxication. Confounding preconceptions, patients in the present study were transferred largely for injuries that required specialized imaging and testing that could not be performed in an out-of-hospital setting. These results suggest that a better understanding of the specific effects on-site HLC teams have on avoiding off-site transfers will aid in improving planning for music festivals. The findings also identify areas for further improvement in on-site care, such as integrated on-site radiology, which could potentially further reduce the impact of music festivals on local health services. The role of non-emergency transport vehicles (NETVs) deserves further attention.TurrisSA, CallaghanCW, RabbH, MunnMB, LundA. On the way out: an analysis of patient transfers from four large-scale North American music festivals over two yearsPrehosp Disaster Med. 2019;34(1):72-81.

Mortality at Music Festivals: An Update for 2016-2017 - Academic and Grey Literature for Case Finding.

In 2016, the authors published a paper on music festival fatalities between the years 1999 and 2014 (n=722). In this Special Report, they provide an update on fatalities reported at music festivals globally for the period 2016-2017 (n=201). Using a search strategy designed to capture grey literature and media reports of music festival fatalities, reports of the overall frequency and cause-of-death breakdown for publicly reported, festival-related deaths are recorded. This update shows an increase in the frequency of festival-related fatality reports during the new period, together with an increase in the number of deaths attributable to terror (n=60) and overdose/poisoning (n=41). Drawing conclusions about the cause of this increase is challenging given the growth in Internet use, online media reports, and number of music festivals occurring annually when compared with the previous reporting period. The authors re-emphasize the need for a uniform reporting standard and reliable epidemiological data for fatalities related to music festivals, mass gatherings, and special events. TurrisSA, JonesT, LundA. Mortality at music festivals: an update for 2016-2017 - academic and grey literature for case finding. Prehosp Disaster Med. 2018;33(5):553-557.

Patient Presentations and Medical Logistics at Full and Half Ironman Distance Triathlons.

We describe logistical challenges, illness/injury rates, as well as medical and ambulance transfer rates (ATR) at an annual large-scale half/full triathlon in a remote location. Prospective observational study; registry data. Data on patient presentation rates, percentage of patients transferred by ambulance, transfer to hospital rates (TTHR), ATR, and medical usage rates were collected and analyzed. In total, 1923 athletes participated in the 2016 triathlon (1404 in the full-length race and 519 in the half) and 181 patient encounters were documented. The patient presentation rate (PPR) was 94 in 1000 patients, and 1.6% of patients seen onsite required offsite medical care. TTHR and ATR were 1.6 in 1000 and 0.5 in 1000, respectively. Gastrointestinal issues were the most common presentation (50/181; 27.6%), followed by musculoskeletal injury (46/181; 25.4%) and nonspecific dizziness (37/181; 20.4%). The incorporation of a coordinated event medical plan and team, with integrated on-course and at-finish coverage, may have minimized presentations of patients to local health care services; therefore, decreasing the effect on the local ambulance service and health infrastructure of the host community.

Mortality at Music Festivals: Academic and Grey Literature for Case Finding.

OBJECTIVE: Deaths at music festivals are not infrequently reported in the media; however, the true mortality burden is difficult to determine as the deaths are not yet systematically documented in the academic literature. METHODS: This was a literature search for case examples using academic and gray literature sources, employing both retrospective and prospective searches of media sources from 1999-2014. RESULTS: The gray literature documents a total of 722 deaths, including traumatic (594/722; 82%) and non-traumatic (128/722; 18%) causes. Fatalities were caused by trampling (n=479), motor-vehicle-related (n=39), structural collapses (n=28), acts of terror (n=26), drowning (n=8), assaults (n=6), falls (n=5), hanging (n=2), and thermal injury (n=2). Non-traumatic deaths included overdoses (n=96/722; 13%), environmental causes (n=8/722; 1%), natural causes (n=10/722; 1%), and unknown/not reported (n=14/722; 2%). The majority of non-trauma-related deaths were related to overdose (75%). The academic literature documents trauma-related deaths (n=368) and overdose-related deaths (n=12). One hundred percent of the trauma-related deaths reported in the academic literature also were reported in the gray literature (n=368). Mortality rates cannot be reported as the total attendance at events is not known. CONCLUSIONS: The methodology presented in this manuscript confirms that deaths occur not uncommonly at music festivals, and it represents a starting point in the documentation and surveillance of mortality. Turris SA , Lund A . Mortality at music festivals: academic and grey literature for case finding. Prehosp Disaster Med. 2017;32(1):58-63.

Mass-gathering Medicine: Risks and Patient Presentations at a 2-day Electronic Dance Music Event - Year Two.

Turris SA , Camporese M , Gutman SJ , Lund A . Mass-gathering medicine: risks and patient presentations at a 2-day electronic dance music event - year two. Prehosp Disaster Med. 2016;31(6):687-688.

Exploring International Views on Key Concepts for Mass-gathering Health through a Delphi Process.

Introduction The science underpinning mass-gathering health (MGH) is developing rapidly. However, MGH terminology and concepts are not yet well defined or used consistently. These variations can complicate comparisons across settings. There is, therefore, a need to develop consensus and standardize concepts and data points to support the development of a robust MGH evidence-base for governments, event planners, responders, and researchers. This project explored the views and sought consensus of international MGH experts on previously published concepts around MGH to inform the development of a transnational minimum data set (MDS) with an accompanying data dictionary (DD). Report A two-round Delphi process was undertaken involving volunteers from the World Health Organization (WHO) Virtual Interdisciplinary Advisory Group (VIAG) on Mass Gatherings (MGs) and the MG section of the World Association for Disaster and Emergency Medicine (WADEM). The first online survey tested agreement on six key concepts: (1) using the term "MG HEALTH;" (2) purposes of the proposed MDS and DD; (3) event phases; (4) two MG population models; (5) a MGH conceptual diagram; and (6) a data matrix for organizing MGH data elements. Consensus was defined as ≥80% agreement. Round 2 presented five refined MGH principles based on Round 1 input that was analyzed using descriptive statistics and content analysis. Thirty-eight participants started Round 1 with 36 completing the survey and 24 (65% of 36) completing Round 2. Agreement was reached on: the term "MGH" (n=35/38; 92%); the stated purposes for the MDS (n=38/38; 100%); the two MG population models (n=31/36; 86% and n=30/36; 83%, respectively); and the event phases (n=34/36; 94%). Consensus was not achieved on the overall conceptual MGH diagram (n=25/37; 67%) and the proposed matrix to organize data elements (n=28/37; 77%). In Round 2, agreement was reached on all the proposed principles and revisions, except on the MGH diagram (n=18/24; 75%). Discussion/Conclusions Event health stakeholders require sound data upon which to build a robust MGH evidence-base. The move towards standardization of data points and/or reporting items of interest will strengthen the development of such an evidence-base from which governments, researchers, clinicians, and event planners could benefit. There is substantial agreement on some broad concepts underlying MGH amongst an international group of MG experts. Refinement is needed regarding an overall conceptual diagram and proposed matrix for organizing data elements. Steenkamp M , Hutton AE , Ranse JC , Lund A , Turris SA , Bowles R , Arbuthnott K , Arbon PA . Exploring international views on key concepts for mass-gathering health through a Delphi process. Prehosp Disaster Med. 2016;31(4):443-453.

Observed Benefits to On-site Medical Services during an Annual 5-day Electronic Dance Music Event with Harm Reduction Services.

BACKGROUND: With increasing attendance and media attention, large-scale electronic dance music events (EDMEs) are a subset of mass gatherings that have a unique risk profile for attendees and promoters. Shambhala Music Festival (Canada) is a multi-day event in a rural setting with a recognized history of providing harm reduction (HR) services alongside medical care. Study/Objective This manuscript describes the medical response at a multi-day electronic music festival where on-site HR interventions and dedicated medical care are delivered as parallel public health measures. METHODS: This study was a descriptive case report. Medical encounters and event-related data were documented prospectively using an established event registry database. RESULTS: In 2014, Shambhala Music Festival had 67,120 cumulative attendees over a 7-day period, with a peak daily attendance of 15,380 people. There were 1,393 patient encounters and the patient presentation rate (PPR) was 20.8 per one thousand. The majority of these (90.9%) were for non-urgent complaints. The ambulance transfer rate (ATR) was 0.194 per one thousand and 0.93% of patient encounters were transferred by ambulance. No patients required intubation and there were no fatalities. Harm reduction services included mobile outreach teams, distribution of educational materials, pill checking facilities, a dedicated women's space, and a "Sanctuary" area that provided non-medical peer support for overwhelmed guests. More than 10,000 encounters were recorded by mobile and booth-based preventive and educational services, and 2,786 pills were checked on-site with a seven percent discard rate. CONCLUSION: Dedicated medical and HR services represent two complementary public health strategies to minimize risk at a multi-day electronic music festival. The specific extent to which HR strategies reduce the need for medical care is not well understood. Incorporation of HR practices when planning on-site medical care has the potential to inform patient management, reduce presentation rates and acuity, and decrease utilization and cost for local, community-based health services.

International Consensus on Key Concepts and Data Definitions for Mass-gathering Health: Process and Progress.

Mass gatherings (MGs) occur worldwide on any given day, yet mass-gathering health (MGH) is a relatively new field of scientific inquiry. As the science underpinning the study of MGH continues to develop, there will be increasing opportunities to improve health and safety of those attending events. The emerging body of MG literature demonstrates considerable variation in the collection and reporting of data. This complicates comparison across settings and limits the value and utility of these reported data. Standardization of data points and/or reporting in relation to events would aid in creating a robust evidence base from which governments, researchers, clinicians, and event planners could benefit. Moving towards international consensus on any topic is a complex undertaking. This report describes a collaborative initiative to develop consensus on key concepts and data definitions for a MGH "Minimum Data Set." This report makes transparent the process undertaken, demonstrates a pragmatic way of managing international collaboration, and proposes a number of steps for progressing international consensus. The process included correspondence through a journal, face-to-face meetings at a conference, then a four-day working meeting; virtual meetings over a two-year period supported by online project management tools; consultation with an international group of MGH researchers via an online Delphi process; and a workshop delivered at the 19thWorld Congress on Disaster and Emergency Medicine held in Cape Town, South Africa in April 2015. This resulted in an agreement by workshop participants that there is a need for international consensus on key concepts and data definitions.

On-site management of medical encounters during obstacle adventure course participation.

Obstacle adventure courses (OAC) are increasing in popularity. Although injuries are not uncommon, there is scant medical literature documenting the morbidity and mortality associated with these events. This manuscript describes a case series. Event demographics, medical coverage, and injuries/illnesses documented during four OAC events in British Columbia, Canada, are discussed - Tough Mudder™ (2012 and 2013) and Warrior Dash© (2011 and 2012). The patient presentation rate across all events ranged from 26.53 to 37.40 per 1,000 participants. Ambulance transfer rates were low (range = 0 to 5 per event day, 0% to 1.1% of patients seen). Although some illness presentations and injuries required a higher level of care, the majority of medical issues were related to musculoskeletal injuries of the lower limbs. Advanced knowledge about risks and patient presentations associated with participation in OAC may influence on-site staffing, deployment patterns, rescue equipment, and transfer to hospital planning for diagnostic imaging and definitive treatment.

Mass-gathering Medicine: Risks and Patient Presentations at a 2-Day Electronic Dance Music Event.

INTRODUCTION: Music festivals, including electronic dance music events (EDMEs), increasingly are common in Canada and internationally. Part of a US $4.5 billion industry annually, the target audience is youth and young adults aged 15-25 years. Little is known about the impact of these events on local emergency departments (EDs). METHODS: Drawing on prospective data over a 2-day EDME, the authors of this study employed mixed methods to describe the case mix and prospectively compared patient presentation rate (PPR) and ambulance transfer rate (ATR) between a first aid (FA) only and a higher level of care (HLC) model. RESULTS: There were 20,301 ticketed attendees. Seventy patient encounters were recorded over two days. The average age was 19.1 years. Roughly 69% were female (n=48/70). Forty-six percent of those seen in the main medical area were under the age of 19 years (n=32/70). The average length of stay in the main medical area was 70.8 minutes. The overall PPR was 4.09 per 1,000 attendees. The ATR with FA only would have been 1.98; ATR with HLC model was 0.52. The presence of an on-site HLC team had a significant positive effect on avoiding ambulance transfers. DISCUSSION: Twenty-nine ambulance transfers and ED visits were avoided by the presence of an on-site HLC medical team. Reduction of impact to the public health care system was substantial. CONCLUSIONS: Electronic dance music events have predictable risks and patient presentations, and appropriate on-site health care resources may reduce significantly the impact on the prehospital and emergency health resources in the host community.

Mass-gathering health research foundational theory: part 2 - event modeling for mass gatherings.

BACKGROUND: Current knowledge about mass-gathering health (MGH) fails to adequately inform the understanding of mass gatherings (MGs) because of a relative lack of theory development and adequate conceptual analysis. This report describes the development of a series of event lenses that serve as a beginning "MG event model," complimenting the "MG population model" reported elsewhere. METHODS: Existing descriptions of "MGs" were considered. Analyzing gaps in current knowledge, the authors sought to delineate the population of events being reported. Employing a consensus approach, the authors strove to capture the diversity, range, and scope of MG events, identifying common variables that might assist researchers in determining when events are similar and might be compared. Through face-to-face group meetings, structured breakout sessions, asynchronous collaboration, and virtual international meetings, a conceptual approach to classifying and describing events evolved in an iterative fashion. Findings Embedded within existing literature are a variety of approaches to event classification and description. Arising from these approaches, the authors discuss the interplay between event demographics, event dynamics, and event design. Specifically, the report details current understandings about event types, geography, scale, temporality, crowd dynamics, medical support, protective factors, and special hazards. A series of tables are presented to model the different analytic lenses that might be employed in understanding the context of MG events. Interpretation The development of an event model addresses a gap in the current body of knowledge vis a vis understanding and reporting the full scope of the health effects related to MGs. Consistent use of a consensus-based event model will support more rigorous data collection. This in turn will support meta-analysis, create a foundation for risk assessment, allow for the pooling of data for illness and injury prediction, and support methodology for evaluating health promotion, harm reduction, and clinical response interventions at MGs.

Mass-gathering health research foundational theory: part 1 - population models for mass gatherings.

BACKGROUND: The science underpinning the study of mass-gathering health (MGH) is developing rapidly. Current knowledge fails to adequately inform the understanding of the science of mass gatherings (MGs) because of the lack of theory development and adequate conceptual analysis. Defining populations of interest in the context of MGs is required to permit meaningful comparison and meta-analysis between events. Process A critique of existing definitions and descriptions of MGs was undertaken. Analyzing gaps in current knowledge, the authors sought to delineate the populations affected by MGs, employing a consensus approach to formulating a population model. The proposed conceptual model evolved through face-to-face group meetings, structured break out sessions, asynchronous collaboration, and virtual international meetings. Findings and Interpretation Reporting on the incidence of health conditions at specific MGs, and comparing those rates between and across events, requires a common understanding of the denominators, or the total populations in question. There are many, nested populations to consider within a MG, such as the population of patients, the population of medical services providers, the population of attendees/audience/participants, the crew, contractors, staff, and volunteers, as well as the population of the host community affected by, but not necessarily attending, the event. A pictorial representation of a basic population model was generated, followed by a more complex representation, capturing a global-health perspective, as well as academically- and operationally-relevant divisions in MG populations. CONCLUSIONS: Consistent definitions of MG populations will support more rigorous data collection. This, in turn, will support meta-analysis and pooling of data sources internationally, creating a foundation for risk assessment as well as illness and injury prediction modeling. Ultimately, more rigorous data collection will support methodology for evaluating health promotion, harm reduction, and clinical-response interventions at MGs. Delineating MG populations progresses the current body of knowledge of MGs and informs the understanding of the full scope of their health effects.

Conceptualizing the impact of special events on community health service levels: an operational analysis.

Mass gatherings (MG) impact their host and surrounding communities and with inadequate planning, may impair baseline emergency health services. Mass gatherings do not occur in a vacuum; they have both consumptive and disruptive effects that extend beyond the event itself. Mass gatherings occur in real geographic locations that include not only the event site, but also the surrounding neighborhoods and communities. In addition, the impact of small, medium, or large special events may be felt for days, or even months, prior to and following the actual events. Current MG reports tend to focus on the events themselves during published event dates and may underestimate the full impact of a given MG on its host community. In order to account for, and mitigate, the full effects of MGs on community health services, researchers would benefit from a common model of community impact. Using an operations lens, two concepts are presented, the "vortex" and the "ripple," as metaphors and a theoretical model for exploring the broader impact of MGs on host communities. Special events and MGs impact host communities by drawing upon resources (vortex) and by disrupting normal, baseline services (ripple). These effects are felt with diminishing impact as one moves geographically further from the event center, and can be felt before, during, and after the event dates. Well executed medical and safety plans for events with appropriate, comprehensive risk assessments and stakeholder engagement have the best chance of ameliorating the potential negative impact of MGs on communities.

An analysis of patient presentations at a 2-day mass-participation cycling event: the Ride to Conquer Cancer Case Series, 2010-2012.

OBJECTIVE: To analyze the unique factors involved in providing medical support for a long-distance, cross-border, cycling event, and to describe patient presentations and event characteristics for the British Columbia (BC) Ride to Conquer Cancer from 2010 through 2012. METHODS: This study was a 3-year, descriptive case series report. Medical encounters were documented, prospectively, from 2010-2012 using an online registry. Data for event-related variables also were reported. RESULTS: Providing medical support for participants during the 2-day ride was complicated by communication challenges, weather conditions, and cross-border issues. The total number of participants for the ride increased from 2,252 in 2010 to 2,879 in 2011, and 3,011 in 2012. Patient presentation rates (PPRs) of 125.66, 155.26, and 198.93 (per 1,000 participants) were documented from 2010 through 2012. Over the course of three years, and not included in the PPR, an additional 3,840 encounters for "self-treatment" were documented. CONCLUSIONS: The Ride to Conquer Cancer Series has shown that medical coverage at multi-day, cross-national cycling events must be planned carefully to face a unique set of circumstances, including legislative issues, long-distance communication capabilities, and highly mobile participants. This combination of factors leads to potentially higher PPRs than have been reported for noncycling events. This study also illuminates the additional workload "self-treatment" visits place on the medical team.

Enhancing the minimum data set for mass-gathering research and evaluation: an integrative literature review.

INTRODUCTION: In 2012, a minimum data set (MDS) was proposed to enable the standardized collection of biomedical data across various mass gatherings. However, the existing 2012 MDS could be enhanced to allow for its uptake and usability in the international context. The 2012 MDS is arguably Australian-centric and not substantially informed by the literature. As such, an MDS with contributions from the literature and application in the international settings is required. METHODS: This research used an integrative literature review design. Manuscripts were collected using keyword searches from databases and journal content pages from 2003 through 2013. Data were analyzed and categorized using the existing 2012 MDS as a framework. RESULTS: In total, 19 manuscripts were identified that met the inclusion criteria. Variation in the patient presentation types was described in the literature from the mass-gathering papers reviewed. Patient presentation types identified in the literature review were compared to the 2012 MDS. As a result, 16 high-level patient presentation types were identified that were not included in the 2012 MDS. CONCLUSION: Adding patient presentation types to the 2012 MDS ensures that the collection of biomedical data for mass-gathering health research and evaluation remains contemporary and comprehensive. This review proposes the addition of 16 high-level patient presentation categories to the 2012 MDS in the following broad areas: gastrointestinal, obstetrics and gynecology, minor illness, mental health, and patient outcomes. Additionally, a section for self-treatment has been added, which was previously not included in the 2012 MDS, but was widely reported in the literature.

An organized medical response for the Vancouver International Marathon (2006-2011): when the rubber hits the road.

OBJECTIVE: We described an organized, on-site medical response for a large-scale urban marathon event and documented illness/injury rates as well as ambulance transfer rates at the Vancouver International Marathon (VIM). METHODS: Case-series report of medical encounters was documented prospectively over a 6-yr period at the VIM. The planning and organization of the on-site medical response is the main focus of this report. RESULTS: A total of 67,402 runners participated in the VIM from 2006 to 2011. Over the 6-yr period, 2,986 patient encounters were documented. The patient presentation rate for the series was 45/1,000, the ambulance transfer rate was 0.09-0.58/1,000, and the medical transfer rate was 0.37-1.09/1,000. CONCLUSION: A coordinated on-site medical team covering the entire event site and race route was deployed to reduce the severity of illness and injury at a long-distance running event.

An Analysis of Mass Casualty Incidents in the Setting of Mass Gatherings and Special Events.

OBJECTIVES: Mass gatherings (MGs) and special events typically involve large numbers of people in unfamiliar settings, potentially creating unpredictable situations. To assess the information available to guide emergency services and onsite medical teams in planning and preparing for potential mass casualty incidents (MCIs), we analyzed the literature for the past 30 years. METHODS: A search of the literature for MCIs at MGs from 1982 to 2012 was conducted and analyzed. RESULTS: Of the 290 MCIs included in this study, the most frequently reported mechanism of injury involved the movement of people under crowded conditions (162; 55.9%), followed by special hazards (eg, airplane crashes, pyrotechnic displays, car crashes, boat collisions: 57; 19.6%), structural failures (eg, building code violations, balcony collapses: 38; 13.1%), deliberate events (26; 9%), and toxic exposures (7; 2.4%). Incidents occurred in Asia (71; 24%), Europe (69; 24%), Africa (48; 17%), North America (48; 27%), South America (27; 9%), the Middle East (25; 9%), and Australasia (2; 1%). A minimum of 12 877 deaths and 27 184 injuries resulted. CONCLUSIONS: Based on our findings, we recommend that a centralized database be created. With this database, researchers can further develop evidence to guide prevention efforts and mitigate the effects of MCIs during MGs. (Disaster Med Public Health Preparedness. 2014;0:1-7).