Factors Influencing Patient Presentation and Transfer to Hospital Rates During Mass-Gathering Stadium Events: A Scoping Review

Abstract

Introduction:

Mass-gathering events (MGEs) such as sporting competitions and music festivals that take place in stadiums and arenas pose challenges to health care delivery that can differ from other types of MGEs. This scoping review aimed to describe factors that influence patient presentations to in-event health services, ambulance services, and emergency departments (EDs) from stadium and arena MGEs.

Method:

This scoping review followed the Preferred Reporting Items of Systematic Reviews and Meta-Analysis for Scoping Reviews (PRISMA-ScR) checklist and blended both Arksey and O’Malley methodology and the Joanna Briggs Institute’s (JBI’s) approach. Four databases (CINAHL, Embase, PubMed, and Scopus) were searched using keywords and terms about “mass gatherings,” “stadium” or “arena,” and “in-event health services.” In this review, the population pertains to the spectators who seek in-event health services, the concept was MGEs, and the context was stadiums and/or arenas.

Results:

Twenty-two articles were included in the review, most of which focused on sporting events (n = 18; 81.8%) and music concerts (n = 3; 13.6%). The reported patient presentation rate (PPR) ranged between one and 24 per 10,000 spectators; the median PPR was 3.8 per 10,000. The transfer to hospital rate (TTHR) varied from zero to four per 10,000 spectators, and the median TTHR was 0.35 per 10,000. Key factors reported for PPR and TTHR include event, venue, and health support characteristics.

Conclusions:

There is a complexity of health care delivery amid MGEs, stressing the need for uniform measurement and continued research to enhance predictive accuracy and advance health care services in these contexts. This review extends the current MGE domains (biomedical, psychosocial, and environmental) to encompass specific stadium/arena event characteristics that may have an impact on PPR and TTHR.

Introduction

A mass-gathering event (MGE) is a planned or spontaneous event where the number of attendees may overwhelm the planning and response resources of the community, state, or nation hosting the event. ¹ There are various types of MGEs, including concerts, sporting events, religious celebrations, street fairs, parades, and political rallies. Each event has a distinct risk profile, with the nature of the event playing a role in determining the associated risks. ² For instance, stadium events are considered bounded, while marathons are unbounded, and this distinction affects the risks of injury or illness. Moreover, attending concerts and sporting events poses certain hazards that can include the possibility of recreational drug and alcohol consumption. ³ Religious gatherings such as Hajj pilgrimage often comprise a majority of older people, which introduces additional considerations for health preparedness. ⁴

Mass-gathering event health care involves providing organized public health and emergency medical care to individuals who gather at a specific location for a defined period of time. ^5–7 These MGEs are complex and can present unique challenges to attendees’ health and well-being. During such MGEs, some participants may require health care for injuries or illnesses, and it is essential to have an in-event health service to limit the impact of MGEs on ambulance and emergency department (ED) services. ⁸ By recording the number of people seeking medical attention, organizers, health care providers, and emergency response teams can better understand the scope and nature of health-related challenges that arise during an MGE. Such information can be used to inform improvements in health care provision.

The patient presentation rate (PPR) is one metric to measure health care usage at an MGE. ⁴ The transfer to hospital rate (TTHR), defined as the rate at which individuals attending an MGE require transportation to a hospital for further medical attention, is another metric. ⁹ Particular factors are known to influence PPR and TTHR from MGEs. ^10–12 In 2004, a fundamental conceptual model for MGEs was proposed to understand and identify three interconnected domains: biomedical, environmental, and psychosocial ² (Figure 1). The original model has evolved with the inclusion of additional domains of the event environment, command, control, communication, public health, health promotion, and legacy. ³ However, due to nuances between MGE types, the determinants specifically related to stadium/arena-based MGEs need to be considered to inform further research. The research question guiding this scoping review was: What factors influence patient (spectators) presentations to in-event health services, ambulance services, and EDs from stadium and arena MGEs?

Figure 1. The Relationship Model of Domains for MGE.²

Note: Used with permission.

Methods

Design

The scoping review followed the Preferred Reporting Items of Systematic Reviews and Meta-Analysis for Scoping Reviews (PRISMA-ScR) checklist ¹³ and elements of the Joanna Briggs Institute (JBI; Adelaide, Australia) methodology, ¹⁴ which includes an outline of the framework proposed by Arksey and O’Malley. ¹⁵ Arskey and O’Malley’s framework consists of six stages. These stages include (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting the data; (5) collating, summarizing, and reporting the results; and (6) consultation (optional).

Search Strategy

With the research question (Stage 1) articulated above, Arskey and O’Mally’s framework ¹⁵ was used to identify relevant studies (Stage 2). Databases were searched in April 2023 (Supplementary Material; available online only). There was no start date for the search, therefore all papers published through April 2023 were included in this search strategy. A thorough search of four different databases was undertaken to gather relevant articles. The databases searched were CINAHL Complete (EBSCO Information Services; Ipswich, Massachusetts USA); Embase (Elsevier; Amsterdam, the Netherlands); PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA); and Scopus (Elsevier; Amsterdam, the Netherlands). To capture pertinent articles, Medical Subject Headings (MeSH) terms and keywords that were specific to MGEs, different types of stadium and arena events, and in-event health services were used. The search strategy considered the Population, Concept, and Context method recommended by the JBI for scoping reviews. ¹⁴ In this review, the population pertained to the spectators who seek in-event health services, the concept was MGE, and the context was stadium and/or arenas. A comprehensive list of MeSH terms and keywords is shown in Table 1. To maximize the search results, authors combined terms and keywords in the columns using the OR search strategy, while terms and keywords in the rows were combined using AND combinations.

Table 1. MeSH Terms and Keywords

Stage 3 of Arskey and O’Mally’s framework ¹⁵ “study selection” included the identification of inclusion and exclusion criteria necessary to establish the review’s boundaries and to identify the studies that aligned with the review question. The inclusion and exclusion criteria of this scoping review are presented in Table 2.

Table 2. Inclusion and Exclusion Criteria

Papers were imported into Covidence (Veritas Health Innovation; Melbourne, Australia). ¹⁶ The study selection process was carried out in three steps. First, two reviewers (NS and JR) reviewed the title and abstract of all articles, and a third reviewer (JC) resolved conflicts. Second, the same two reviewers (NS and JR) reviewed the full text of the articles to determine the eligibility of the study based on the inclusion and exclusion criteria outlined in Table 2, and a third reviewer (JC) resolved any disagreements in a blinded manner. Third, one reviewer (NS) extracted data manually from the included papers, a summary of which is outlined in Table 3 and Table 4. The second (JR), third (JC), and fourth reviewer (RW) split and crosschecked the data extracted.

Table 3. Summary of In-Event and External Health Services of Mass-Gathering Stadium/Arena Events.

Abbreviations: ED, Emergency Department; IR, Incidence Rate; MLB, Major League Baseball; MGE, Mass-Gathering Event; USA, United States of America; UK, United Kingdom; PPR, Patient Presentation Rate; TTHR, Transport to Hospital Rate.

Table 4. Factors Affecting Patient Presentation Rate and Transfer to Hospital Rate.

Abbreviations: ED, Emergency Department; GP, General Practitioner; EMT, Emergency Medical Technician; EMS, Emergency Medical System; IVT, Intravenous Vitamin Therapy; IVD, In Vitro Diagnostics; GTN, Glyceryl Trinitrate; O2, Oxygen; ICD-10, International Classification of Diseases 10^th Revision.

Data Collection and Data Synthesis

Charting the data (Stage 4) and collating, summarizing, and reporting the results (Stage 5) were undertaken, per Arskey and O’Mally.¹⁵ Information extracted from each article was recorded in two Microsoft 365 Word tables (Microsoft Corporation; Redmond, Washington USA). The first table included the author(s), year of publication, year of the MGE, country, MGE type, study population and sample size, in-event presentation, and hospital presentation. Two different ways were used to present in-event and hospital data. One method was to report the exact values found in the articles, such as raw values, mean values, PPR per 1,000 or 10,000, and TTHR per 1,000 or 10,000. The other method involved calculating the PPR and TTHR per 10,000, even when the original articles did not specify these measures in that format. The second table included factors affecting PPR and TTHR, grouped into six different domains; three (biomedical, environmental, psychosocial) from an earlier framework² and three (event characteristics, venue characteristics, and health care characteristics) from further information elicited from this review. Data are reported using descriptive statistics.

Results

Out of 1,009 articles identified, 267 were duplicates and 688 were excluded at the title and abstract screening stage. The full text of 53 articles was reviewed, and after 31 were excluded, 22 articles that met criteria were included (Figure 2). Of the 22 articles, three (13.6%) were focused on concerts, one (4.6%) covered Pope Francis’s religious visit, and the remaining 18 (81.8%) were sports MGEs, including football, cricket, basketball, baseball, rugby, the Olympics, and the Athletics World Championships. Thirteen (59.1%) articles were MGEs in the United Kingdom (n = 6) and United States of America (n = 7). Table 317-39 provides a summary of the characteristics of the 22 included articles.

Figure 2. PRISMA Flow Diagram of Included Articles for this Scoping Review.

In-Event Patient Presentation Rates

The PPR was reported in different ways. Some measured PPR as per 1,000 spectators (n = 7; 31.8%), while others presented it as per 10,000 spectators (n = 10; 45.5%). Some authors reported the total number of patients (n = 20; 90.9%), the mean number of patients (n = 6; 27.3%), or the PPR per game (n = 1; 4.6%). When the PPR for each article was adjusted to 10,000 by the authors of this review, the PPR varied from one to 24 per 10,000, and the median PPR was 3.8 per 10,000 spectators. The highest reported PPR was noted to occur during the 2009 Summer Cricket Season in the United Kingdom (24 per 10,000).

Transfer to Hospital Rates

During MGEs, patients may require an ambulance transfer to a hospital’s ED due to needing higher levels of care. Whilst some articles measured the TTHR per 1,000 spectators (n = 2; 9.1%) or 10,000 spectators (n = 3; 13.6%), most articles reported the total number (n = 15; 68.2%) and/or the percentage (n = 10; 45.5%) of spectators who received in-event health care and were transported to the hospital from the MGE. When the TTHR for each article was adjusted to 10,000 by the authors of this review, the TTHR varied from 0.01 to four per 10,000, and the median TTHR was 0.35 per 10,000 spectators. The highest TTHR was during the football season in Belgium, which was four per 10,000 spectators.

Factors Reported for PPR and TTHR

Biomedical, environmental, and psychosocial factors that may have contributed to PPR and TTHR that were reported by authors are summarized in Table 4.^17-39

Age and gender were common biomedical factors reported, noted in 15 (68.2%) articles. Male (n = 10) spectators were more likely to be injured than females (n = 5). The severity of illness was also a biomedical factor reported in some articles (n = 7; 31.8%). The weather was identified as an important environmental factor in the majority of articles (n = 12; 54.6%). Weather factors reported included temperature (minimum and maximum), such as an increase in daily maximum temperatures; heat index (the perceived temperature influenced by both temperature and humidity); air quality (classified as good, fair, or poor, depending on the presence of dust, gas, mist, odor, or smoke in crowded places); rainfall; humidity (average); and wind direction (which helps measure weather patterns). The first two factors, temperature and heat index, were the most commonly reported. A statistical correlation was found between the game-time heat index and the volume of patients; however, cold weather also affected spectators’ health. Psychosocial factors reported included alcohol consumption (n = 7; 31.8%), drug use (n = 2; 9.1%), and crowd behavior (n = 1; 4.6%). Of these, alcohol consumption was a factor that considerably influenced PPR and TTR.

In addition to biomedical, environmental, and psychosocial factors, other categories of factors were identified, which authors categorized as event-specific characteristics, venue characteristics, and health support at the venue as these varied from event to event. Event characteristics were reported such as crowd size (n = 8; 36.4%), the timing of the event (n = 4; 18.2%), availability of drinking water (n = 1; 4.6%), and day of the event (opening/closing ceremony; n = 1; 4.6%). Venue characteristics included venue infrastructure, which was mostly permanent in stadiums or arenas. Reported issues with venue infrastructure pertained to broken pavement, entry turnstiles, uneven flooring, broken handrails, seating design, number of levels, indoor or outdoor setting, fenced perimeter, maximum capacity (n = 4; 18.2%), and the location of the first aid station (n = 1; 4.5%). Health support characteristics reported included the number of first aid stations (n = 10; 45.5%) and the presence of health care providers including doctors, nurses, paramedics/Emergency Medical Technicians (EMTs), first aiders, and Basic Life Support teams (n = 14; 63.6%). Additionally, having enough medical equipment (n = 3; 13.6%), ambulances and trained ambulance crew (n = 12; 54.6%), treatment type (n = 6; 27.3%), and shorter transfer times to the hospital (n = 1; 4.6%) were factors that were reported to reduce the vulnerability of patients during MGEs.

Discussion

This review identified three key findings regarding presentations to health services at MGEs. First, three additional domains were identified to extend upon Arbon’s earlier framework² for MGEs that are specific to stadiums/arenas. Second, PPR and TTHR are variably reported and vary considerably. Third, factors influencing PPR and TTHR that are specific to stadiums/arenas are articulated according to the six domains outlined. With the emerging evidence on stadium and arena MGEs identified and reported on in this scoping review, along with the three traditional biomedical, environmental, and psychosocial domains identified by Arbon,² authors encourage others planning future research or planning future MGEs being held in stadiums or arenas to consider three additional domains: event characteristics, venue characteristics, and health support characteristics. As depicted in Figure 3, the expanded framework accounts for the consideration of certain event characteristics, venue characteristics, and availability and type of health support at the MGE, which can vary depending on the event.

Figure 3. Proposed Framework for Stadium/Arena Event Mass Gatherings.

This review highlighted that patient-level data are variably reported in articles about stadiums and arenas. Important metrics such as PPR and TTHR are reported in different units² ranging from per 100 to per 10,000. While there have been several articles on PPR and TTHR at MGEs, the majority haven’t been on stadium or arena MGEs.¹² Standardizing and systematizing the measurements of health outcomes associated with MGEs will enhance the accuracy and reliability of reported data, contributing to the overall quality of epidemiological information.¹² A consistent measure of stadium safety may be the occurrence of major incidents.¹⁷ To gain a better understanding of health care needs at stadiums and arenas, it must be ensured that the same variables and units of measurement are consistently reported, an issue and recommendation noted by others.¹⁸

This article presents a framework of six domains that can be viewed as determinants, similar to Arbon’s prediction model.¹¹ Interestingly, there is a lack of comprehensive studies on stadium/arena MGEs that illustrate the relationship between these factors. Most articles simply present statistical data in terms of frequencies and percentages. For instance, crowd numbers are a common factor that significantly influences the PPR and TTHR.^19,20 However, other crucial factors need to be considered to understand their impact on PPR and TTHR. Nevertheless, predicting the PPR and TTHR is critical for well-organized MGEs. A comprehensive understanding of PPR and TTHR requires exploring their associations with all the different factors related to stadium and arena MGEs. The importance of the factors will be assessed in future research, using statistical models against patient level data from multiple stadium and arena events.

Study Limitations

Despite the existing research, gaps remain in understanding health care provision in stadium and arena settings and in applying findings to different types of events and global contexts. The use of different measuring tools makes it challenging to summarize information about PPR and TTHR. To enhance the provision of optimal health care services at mass-gathering stadium/arena events, all major factors contributing to PPR and TTHR need to be taken into consideration. The factors have been derived from the reported variables within the reviewed papers; these variables have not been mathematically validated in these papers. More advanced statistical predictive models are one approach that can be used to predict PPR and TTHR, taking into account all major determinants. Addressing these challenges can help stakeholders better prepare for and support the health and safety of attendees, making MGEs enjoyable and secure for participants.

Conclusion

This scoping review offers a comprehensive overview of the factors that influence health care utilization and outcomes during stadium and arena MGEs. The review emphasizes the intricate interplay of biomedical, environmental, psychosocial, event-specific, venue-related, and health care support factors. Even though the proposed conceptual model is specifically for stadium and arena MGEs, the model has relevance and adaptability to the non-stadium MGEs. It highlights the need for personalized and forward-thinking health care planning and resource allocation to keep participants safe and healthy at future MGEs. By gaining a deeper understanding of these influencing factors, it is possible to improve the effectiveness of health care strategies for MGEs and to ensure the well-being of all participants.