Abstract
The National Association of Emergency Medicine Services (EMS) Physicians (NAEMSP) recognizes the continued growth and complexity of mass gathering events and the integral role of the medical director in their planning and management. There is a growing body of literature that provides additional insight into patient presentations as well as preparation, staffing, and planning for these events. The clinical practice of EMS medicine encompasses the provision of care in a variety of out-of-hospital environments, including those defined as mass gathering events. This updated guidance is intended for use by EMS personnel, EMS medical directors, emergency physicians, and other members of the multidisciplinary care team as they strive to provide the best care for patients in a variety of out-of-hospital environments. This document is not meant to be a complete review of all the issues on this topic, but rather a consensus statement based on the combination of available peer-reviewed, published evidence and expert opinion.
Introduction
Mass gatherings have been variably defined. Most experts favor a definition that focuses on necessary resources, as opposed to an exact number of attendees at a given event. However, a common reference defines mass gathering events as those with over 1,000 persons, but most published data are from events with greater than 25,000 people in attendance (Citation1). FEMA uses the term “special events,” which is defined as a non-routine event that strains the resources of the hosting community and requires special permitting or additional planning, preparation, and mitigation. Emphasis is not placed on the total number of people attending, but rather the effect on the hosting community’s ability to respond to a large-scale emergency or disaster.
The more common mass gathering event types include musical events, religious proceedings, sporting events and competitions, parades and fairs, and political rallies (Citation2, Citation3). Each event potentially presents unique medical and logistical challenges. In recent years, we have gained additional understanding about potential threats that include: penetrating and blunt trauma from terrorism, stampedes and structural collapses, communicable diseases, and toxicological and environmental emergencies.
The National Association of EMS Physicians recommends
The goals of health and medical care at mass gathering events are to:
Provide initial stabilization on-site including expedient critical care interventions, treatments, and medications to participants, support staff, and spectators.
Decrease the burden on host jurisdictional resources, including EMS and healthcare infrastructure. This may include on site care, observation and alternative disposition under the oversight of the physician medical director and in accordance with local law.
Prepare for and respond to a mass casualty incident (MCI).
Provide care at least commensurate with local standards of care.
The Medical Director should:
Be a physician who is knowledgeable regarding EMS, emergency medical conditions, and their treatment, as well as logistical and personnel limitations inherent in mass gatherings.
Have an active leadership role in developing the event Medical Plan, which should be documented on Incident Command System (ICS) Form 206, and provide oversight of the development of the Safety Plan, which should be documented on ICS Form 208.
Oversee EMS clinician credentialing and their treatment capability with respect to local scope of practice and protocols.
Participate with other key members of the unified command system in preplanning for MCIs at the event, including law enforcement, fire, rescue, and EMS operations leadership.
Event resource planning should:
Use predictive modeling to assist event planners and medical directors in forecasting medical utilization, recognizing models have inherent limitations (Citation4, Citation5).
Incorporate historical data from similar previous events to help predict future needs (Citation6).
Account for event-specific factors that have been shown to affect the patient presentation rate (PPR) or medical utilization rate (MUR) (Citation7).
Consider the transfer to hospital rate (TTHR) to help quantify the impact of onsite care, including physician staffing, on event dedicated and surrounding EMS and acute care resources.
Essential components of the medical plan should include:
The location and capacity of treatment areas, staffing and associated level of medical care, basic life support (BLS), and advanced life support (ALS) transport options, air medical assets, and hospitals with associated capabilities. ICS Form 206 can be used as a helpful resource, and should be completed as part of the development of a comprehensive Incident Action Plan (IAP).
A map outlining venue boundaries, medical care stations, routes of travel, points of ingress and egress, EMS staging locations, casualty collection points, and landing zones for air medical assets, if indicated.
A medical threat assessment based on gathered medical intelligence that could affect the PPR/MUR or TTHR.
Integration of the public health system is necessary and:
Disease surveillance is critical, especially at larger scale events, to detect not only outbreaks of infectious pathogens but also the deliberate use of chemical, biological, or radioactive materials.
Should incorporate a plan that addresses risk mitigation in inclement weather, potable water sources, food safety, sanitation, and shelter from the environment.
The event medical director should consider reviewing public health threats and associated mitigation strategies with jurisdictional public health and emergency preparedness authorities.
Should include pre-event designated audio and visual messaging per the public address system to assist with spectator guidance.
Knowledge of historical and current disease prevalence trends is important to inform the development of countermeasures and/or warnings to attendees.
Documentation expectations should be well defined and:
The patient care record should be tailored to work within the event environment and should balance efficiency and thoroughness.
Should be adaptable to the clinical situation and the level of care provided.
Data from documentation can help to inform future medical supply and equipment needs as well as staffing.
Ensure security of the medical record from initial generation through review to storage.
Communications should:
Include multiple modes with interoperable capabilities to ensure redundancy.
Be trialed to ensure transmission is clear, reliable, and uninterrupted.
Exist on a dedicated medical channel separate from the event and also distinct from the surrounding jurisdiction.
Interface with the host jurisdictions public safety answer point.
Have a predesignated channel established for an MCI.
Include social media sites which may also be useful to gather early information about a developing incident and/or as a method of information dissemination to the public.
Coordinated in a plan, which should be documented on ICS Form 205.
Quality management should:
Include an assessment of the event planning stages through an after-action review.
Review refusal of medical assistance (RMA) and leaving against medical advice (AMA).
Review treat and release encounters as well as those that required patient transport.
Review patient care documentation to identify elements of the system and patient care that are performing well and where additional education and improvement may be needed.
Include joint review with outside agencies if they were also involved in the response.
Use accepted metrics such as PPR, MUR, and TTHR, which provide important information and enable comparisons to be made with respect to medical resource utilization.
Include a formal after-action review to be completed and reviewed as soon as possible following the end of the event.
Mass Casualty Incident planning:
Event planners should utilize the Incident Command System for command and control of resources responding to an MCI.
The ability to quickly, and efficiently, expand the scope of response to an incident should be considered in the development of all mass gathering plans.
Triage algorithm(s) and casualty collection point(s) should be identified.
The plan should be practiced via tabletop exercise or live drills involving all stakeholders to ensure it meets the needs for the event and possible threats.
The plan should be regularly reviewed and updated.
References
- Brown J, Smith JG, Tartaris K. Medical management of mass gathering. In: Klauer K, editor. Emergency medical services: clinical practice and systems oversight. 2nd ed. Chichester (UK): John Wiley & Sons Inc.; 2015. p. 264–71.
- Chan C, Friedman M. Onsite medical care, resuscitation increasingly important at mass gathering events. ACEP Now. 2017;36(4):11–12.
- Hutton A, Ranse J, Verdonk N, Ullah S, Arbon P. Understanding the characteristics of patient presentations of young people at outdoor music festivals. Prehosp Disaster Med. 2014;29(2):160–6. doi:10.1017/S1049023X14000156.
- Locoh-Donou S, Yan G, Berry T, O’Connor R, Sochor M, Charlton N, Brady W. Mass gathering medicine: event factors predicting patient presentation rates. Intern Emerg Med. 2016;11(5):745–52. doi:10.1007/s11739-015-1387-1.
- Van Remoortel H, Scheers H, De Buck E, Haenen W, Vandekerckhove P. Prediction modelling studies for medical usage rates in mass gatherings: a systematic review. PLoS One. 2020;15(6):e0234977 doi:10.1371/journal.pone.0234977.
- Zeitz KM, Zeitz CJ, Arbon P. Forecasting medical work at mass-gathering events: predictive model versus retrospective review. Prehosp Disaster Med. 2005;20(3):164–8. doi:10.1017/s1049023x00002399.
- Ranse J, Hutton A, Turris SA, Lund A. Enhancing the minimum data set for mass-gathering research and evaluation: an integrative literature review. Prehosp Disaster Med. 2014;29(3):280–9. doi:10.1017/S1049023X14000429.