Ranse, J., Lenson, S., Keene, T., Luther, M., Burke, B., Hutton, A., & Jones, N. 2015. Patient presentations and health service impact: A case study from a mass gathering. [Report]

1. PATIENT PRESENTATIONS AND
HEALTH SERVICE IMPACT:
A CASE STUDY FROM A MASS
GATHERING
This research was generously supported by a St John Ambulance Australia research grant.

2. RESEARCH TEAM
CO-RESEARCHERS
Mr Jamie Ranse1,2
Mr Shane Lenson3,4
Mr Toby Keene5
Mr Matt Luther6
Dr Brandon Burke7
A/Prof Alison Hutton2
RESEARCHER ASSISTANT
Ms Nicole Jones1
AFFILIATIONS
1. University of Canberra, University Drive, Bruce ACT 2617
2. Flinders University, Sturt Road, Bedford Park SA 5042
3. Australian Catholic University, Antill Street, Watson ACT 2602
4. St John Ambulance Australia, Thesiger Court, Deakin ACT 2600
5. ACT Ambulance Service, Amberley Avenue, Majura ACT 2609
6. Calvary Health Care ACT, Mary Potter Circuit, Bruce ACT 2617
7. Canberra Hospital, Yamba Drive, Garran ACT 2605

3. INTRODUCTION
BACKGROUND
A mass gathering can be defined as an event where a group of people come together for a common
purpose within a particular space or venue. Further, a mass gathering can be defined as an event
“where there is the potential for a delayed response to [health] emergencies”.1
A number of
challenges in providing adequate health care exist at a mass gathering, primarily related to the
environment and patient egress.2
Within the mass gathering environment health providers aim to
maximize their efficiency in responding to health emergencies, whilst minimizing the disruption to the
normal operational capacity of the health service in the surrounding community or region. As such, a
detailed health plan for mass gatherings is vital to ensure adequate health outcomes for participants,
spectators and the broader host community. As the science underpinning mass gathering health is
developing, so are specific ways of measuring and evaluating care at these events.3
The mass gathering literature commonly reports on the onsite care from single events, and does not
consider the effect on prehospital or hospital services. One recent example within the Australian
Capital Territory explored the patient presentations at the 24-hour mountain biking championships.4
The international mass gathering literature too focuses on the on-site first aid or health professional
services and patient presentations. In addition there is no peer-reviewed literature that links the
provision of care and patient presentation characteristics between on-site first aid providers with
other health services, such as the local government statutory ambulance provider and the local
hospital services.
AIM
This research aims to enhance the understanding of the health service requirements at an outdoor
music festival by describing the health service usage in one Australian jurisdiction. In particular, this
research aims to describe the patient characteristics for the following patient populations:
1) Those patients who presented for onsite care at the event, provided by St John Ambulance
Australia (ACT),
2) Those patients whose care was escalated to onsite doctors, nurses and paramedics
volunteering at the event with St John Ambulance Australia (ACT),
3) Those patients whose care was escalated to the care of ACT Ambulance Service, and
4) Those patients who had care provided at either the Canberra Hospital or Calvary Hospital in the
ACT.

4. METHODS
DESIGN
This research used a retrospective analysis of patient care records.
SETTING
This research was set at one outdoor music festival in 2012. The outdoor music festival was held in
Canberra, Australia, an inland city with a population of approximately 350,000 people. Approximately
20,000 people attended this twelve-hour outdoor music festival. The event was bounded and ticketed.
Alcohol was available for purchase at the event; participants were not permitted to bring alcohol from
outside the event. The festival had one first aid post and a health team staffed by doctors, nurses and
paramedics.
POPULAITON AND SAMPLE
The population includes the approximately 20,000 participants. The sample included all participants of
the population who presented to onsite first aid care for assessment and/or management and had a
patient care record completed.
DATA COLLECTION
Data was collected from patient care records from providers of event health services (St John
Ambulance Australia [ACT]). These records were linked with prehospital (ACT Ambulance Service) and
hospital (Canberra Hospital and Calvary Health Care ACT) records using a pre-existing minimum
dataset for mass gathering research and evaluation [see below].3

5. METHODS
DATA ANALYSIS
Data analysis included descriptive statistics such as means of central tendency and frequency
distributions. Descriptive statistics were used in relation to demographic and presentation details.
Additionally, a Mann-Whitney U Test was used to explore the length of stay between onsite first aid
care and onsite health professional care. Data was analysed using Microsoft Excel.
PROTECTION OF HUMAN PARTICIPANTS
This research was approved by the St John Ambulance Australia Human Research Ethics Committee.
There were no research difficulties or disputes resulting from this research.

6. RESULTS
The following section outlines the key results of this research. In particular this section focuses on the
patient presentations to the various health services. Figure 1 provides an overview of the patient
distribution and outcomes associated with attendance at this mass gathering.
Figure 1: patient distribution to health services and outcomes
ONSITE FIRST AID CARE
Of the 20,000 spectators at this event, 197 (9.85/1,000) persons presented to onsite first aid care. The
majority were female (n=119, 64%). The most frequent illness was headaches (n=94), injury was
superficial lacerations (n=13), environmental was substance and/or alcohol intoxication (n=12). The
majority of patients were discharged and returned to the event, while 24 people were referred to
onsite health professional care.

7. RESULTS
ONSITE HEALTH PROFESSIONAL CARE
Of the 24 (1.2/1,000) presentations to onsite doctors, nurses and paramedics, there were equal
proportions of males and females. The mean (standard deviation) length of stay in minutes was 76 (+/-
45). There was a statistically significant difference between the time patients were assessed and
managed by the onsite first aid care when compared to the onsite health professional care (p=<0.001).
The most frequent illness was headaches (n=3), injury was fractures (n=2), environmental was
substance and/or alcohol intoxication (n=12). Of the 24 who received onsite health professional care,
two were discharged to police due to aggression, seven transported to hospital, the remaining 15
returned to the event.
AMBULANCE PARAMEDIC CARE AND TRANSPORTATION
Seven patients (0.35/1,000) were referred to ambulance paramedic care, all of whom were
transported to hospital. Of this patient population, the most frequent injury was fractures (n=2), and
environmental was substance and/or alcohol intoxication (n=4). One patient required prehospital
endotracheal intubation and an additional three patients required airway adjuncts. Six patients
received intravenous medications from paramedics including opioids.
HOSPITAL AND HEALTH SERVICE PROVIDERS
Of the seven patients (0.35/1,000) that presented to hospital, one patient (0.05/1,000) required the
use of the operating theatre, for an open reduction and internal fixation. One patient (0.05/1,000)
required intubation and ventilator support in the Intensive Care Unit. The remaining five required less
than 24 hours in the emergency department / short stay unit.

8. DISCUSSION
ONSITE CARE
GENDER
Females dominated the number of presentations to onsite first aid care at this mass gathering. This is
a similar finding to other mass gathering research relating to Australian outdoor music festivals.
However, it is interesting that there was parity between genders of those who required onsite health
professional care. Perhaps this highlights that males present to onsite first aid care less frequently
than females, however, males present more acutely unwell. Further research would be required to
explore this inference.
ONSITE HEALTH PROFESSIONALS AS A MODEL OF CARE
Of the 24 patients who received onsite health professional care, 15 were assessed, clinically managed
and discharged to the event. Traditionally, patients from a mass gathering that require ongoing care
would be transported to hospital. However, with onsite health professionals at this event, a model of
keeping patients and managing their symptoms was adopted. This model of care may have resulted in
15 patients avoiding the use of local ambulance and hospital services. However, ambulance and
hospital avoidance requires further evaluation.
Patients who received care from onsite health professionals had an increased length of stay onsite
when compared to those who were managed by the first aid services. This is not surprising as those
managed by onsite health professionals are presumably more acutely unwell, and required time to
relieve their presenting symptoms. Future evaluations of this model of care should include the
economic value and viability. This should be considered in the context of reducing the disruption to
the normal operational capacity of the health service in the surrounding community or region. In the
meantime, this model of care seems reasonable.
AMBULANCE PARAMEDIC CARE AND TRANSPORTATION
All patients who were referred to ambulance paramedics for assessment and/or management were
transported to hospital. This was the first research to explore the usage of ambulance paramedics at a
mass gathering. Additional research should be undertaken to explore the role of paramedics at mass
gatherings, and more broadly the effectiveness of having ambulance services based onsite resources
at mass gatherings.

9. DISCUSSION
HOSPITAL AND HEALTH SERVICE PROVIDERS
Hospitals and health service providers should be aware of mass gatherings in their local community.
Mass gatherings do increase the workload of these health services. This research has demonstrated
that 0.35 per 1,000 participants from this mass gathering required the usage of the local emergency
departments. Additionally, 0.05 per 1,000 required the use of an operating theatre and 0.05 per 1,000
required the use of an intensive care unit. A multisite study to specifically explore the effect of mass
gatherings of emergency department, intensive care and perioperative environments would be
important. However, health services should consider additional human and physical resources if a
larger mass gathering is planned in their region.
LIMITATIONS
This research was undertaken at a single mass gathering. As such the findings from this research may
not be more generalizable to other mass gatherings. Future, research should include multi-site
research from multiple mass gatherings in multiple health services.

10. CONCLUSION
This research is unique in providing a linkage of patient presentation characteristics from one mass
gathering in one region between multiple health services. A linkage between multiple health services
from a mass gathering has not previously been reported in the literature. It is anticipated that this
research will be a pilot for future studies, linking data from multiple events with multiple services to
gain a better understanding of the planning requirements for mass gatherings. Such understanding
may influence the health workforce and resource management of health services in regions where
mass gatherings occur.

11. REFERENCES
1. Arbon P. Mass-gathering medicine: A review of the evidence and future directions for research.
Prehosp Disaster Med. 2007; 22(2):131-135.
2. Ranse J, Zeitz K. Chain of survival at mass gatherings: A case series of resuscitation events.
Prehosp Disaster Med. 2010; 25(5):457-463.
3. Ranse J, Hutton A. Minimum data set for mass-gathering health research and evaluation: A
discussion paper. Prehosp Disaster Med. 2012;27(6):543-550.
4. Taylor N, Ranse J. Epidemiology of injuries at the Australian 24 hour mountain bike
championships. Australasian Journal of Paramedicine. 2013;10(1)a4:1-5.