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The Event Chain of Survival in the Context of Music Festivals: A Framework for Improving Outcomes at Major Planned Events

Published online by Cambridge University Press:  20 March 2017

Adam Lund  and
Sheila Turris
Adam Lund*
Affiliation:
University of British Columbia, Mass-Gathering Medicine Interest Group, Department of Emergency Medicine, Vancouver, British Columbia, Canada Royal Columbian Hospital, Emergency Department, New Westminster, British Columbia, Canada University of British Columbia, School of Nursing, Vancouver, British Columbia, Canada
Sheila Turris
Affiliation:
University of British Columbia, Mass-Gathering Medicine Interest Group, Department of Emergency Medicine, Vancouver, British Columbia, Canada Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
*
Correspondence: Adam Lund, MD University of British Columbia #316 - 255 Newport Drive Port Moody, British Columbia V3H 5H1 Canada E-mail: adam.lund@ubc.ca
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Abstract

Despite the best efforts of event producers and on-site medical teams, there are sometimes serious illnesses, life-threatening injuries, and fatalities related to music festival attendance. Producers, clinicians, and researchers are actively seeking ways to reduce the mortality and morbidity associated with these events. After analyzing the available literature on music festival health and safety, several major themes emerged. Principally, stakeholder groups planning in isolation from one another (ie, in silos) create fragmentation, gaps, and overlap in plans for major planned events (MPEs).

The authors hypothesized that one approach to minimizing this fragmentation may be to create a framework to “connect the dots,” or join together the many silos of professionals responsible for safety, security, health, and emergency planning at MPEs. Adapted from the well-established literature regarding the management of cardiac arrests, both in and out of hospital, the “chain of survival” concept is applied to the disparate groups providing services that support event safety in the context of music festivals. The authors propose this framework for describing, understanding, coordinating and planning around the integration of safety, security, health, and emergency service for events. The adapted Event Chain of Survival contains six interdependent links, including: (1) event producers; (2) police and security; (3) festival health; (4) on-site medical services; (5) ambulance services; and (6) off-site medical services.

The authors argue that adapting and applying this framework in the context of MPEs in general, and music festivals specifically, has the potential to break down the current disconnected approach to event safety, security, health, and emergency planning. It offers a means of shifting the focus from a purely reactive stance to a more proactive, collaborative, and integrated approach. Improving health outcomes for music festival attendees, reducing gaps in planning, promoting consistency, and improving efficiency by reducing duplication of services will ultimately require coordination and collaboration from the beginning of event production to post-event reporting.

LundA, TurrisSA. The Event Chain of Survival in the Context of Music Festivals: A Framework for Improving Outcomes at Major Planned Events. Prehosp Disaster Med. 2017;32(4):437–443.

Keywords

chain of survivalharm reductionmass gatheringsmass-gathering healthmusic festivals
Type
Special Reports
Information
Prehospital and Disaster Medicine , Volume 32 , Issue 4 , August 2017 , pp. 437 - 443
Copyright
© World Association for Disaster and Emergency Medicine 2017 

Introduction

Sudden death and serious medical presentations, including mass-casualty incidents, are not rare occurrences in the context of major planned events (MPEs).Reference Hsieh, Ngai, Burkle and Hsu 1 - Reference Turris, Lund and Bowles 4 Music festivals are extremely popular, enriching community events that attract primary target audiences of youth and young adults aged 15-25 years.Reference Carmichael 5 - Reference Weir 9 Unfortunately, despite the best efforts of event producers and on-site medical teams, there are regularly reported serious illnesses, significant injuries, and fatalities.Reference Madert 10 - Reference Romero 19 These fatalities are more frequently reported in the media than in the body of academic literature describing MPEs.Reference Romero 19 - Reference Boles 52

Event producers, clinicians, and researchers are actively seeking ways to reduce the mortality and morbidity associated with music festivals. Most MPEs represent temporary “systems” or “communities,” and the event medical team is most commonly conceived as the emergency response portion of that system. When event design, production, and security do not coordinate with on-site medical services, potential gaps and/or overlap are created in event safety, security, health, and emergency planning. Depending on the jurisdiction, there may be no direct connection between the contracted event medical team and the community’s public health and acute/emergent care infrastructure. These host community stakeholders may in turn set expectations upon event producers based on concerns regarding health impacts on their community; and, they may mandate a higher level of standby ambulance service and/or hospital staffing than might be required with a more integrated approach. A framework to “connect the dots,” or join together the many categories of professionals who participate in the production of MPEs, is required.

The authors hypothesize that poor event health outcomes and disconnected safety, security, health, and emergency services are related issues. In this paper, the authors propose the adaptation of a framework for describing, understanding, coordinating, and planning around safety and health care service integration for MPEs, using the context of music festivals as an exemplar. This framework is based on the “chain of survival” described in the resuscitation literature.Reference Cummins, Ornato and Thies 53 The authors argue that adapting and applying this framework provides a familiar foundation from which to improve planning and coordination between groups involved in event safety and health services at special events.

Background

Mortality and Morbidity at Music Festivals

Music festival fatalities, regrettably, are not rare events. A recent literature review was carried out using published health literature and gray literature as sources of data (in review).Reference Archer, Beaumont, May, Dargan and Wood 54 There have been more than 700 deaths at music festivals in the last 15 years; deaths are related primarily to trauma and substance use. In addition to fatalities, music festivals can create a substantial impact on health service infrastructure in the local community.Reference Turris and Lund 55 - Reference Hutton, Savage, Ranse, Finnell and Kub 67 The range of causes of death and types of injuries that have occurred at music festivals confirms the need for multi-agency, multi-disciplinary team planning around safety, security, health, and emergency services.

Responsibility for health outcomes in the context of MPEs is unclear. Those with a stated or assumed responsibility include event producers, permit-grantors, public health, security and policing, health advocacy groups, attendees, volunteer and contracted event medical services (on-site) providers, local and contracted ambulance services, local hospitals, and health authorities. Each team, members of a particular professional group (eg, police, security, or health care), expends resources in order to plan for and optimize service delivery in their own silos. Each may make assumptions about the services provided by others, leading to both overlap (wasteful), and worse, a gap that fails to eliminate or mitigate a risk to attendees.

Consensus Evidence

A review of available case studies on music festivals (and one case series) illuminates the following issues of concern to researchers and those responsible for safe event planning:

  1. 1. The need for consistent, evidence-based, policy approaches to event safety, illness prevention, and mitigation of harm (eg, bag searches at the gate, amnesty bins, police drug-sniffing dogs, shelter requirements, access to potable water, or open carry alcohol policies versus alcohol sales confined in one or a few areas of the festival);Reference Lund and Turris 2

  2. 2. The need to further develop the understanding of youth culture, risk-taking, and decision-making processes;Reference Jenkinson, Bowring, Dietze, Hellard and Lim 60 , Reference Hutton, Savage, Ranse, Finnell and Kub 67

  3. 3. The role of harm reduction at music festivals and the challenges associated with this integration given diverse issues such as legislation and concern that harm-reduction initiatives may be perceived as supporting substance use;Reference Munn, Lund, Golby and Turris 64

  4. 4. A growing understanding that the integration of “higher level of care” providers on prehospital teams, preferably with an emergency medicine background, is paramount to avoid burdening the health care system in the host community;Reference Lund and Turris 2 , Reference Bledsoe, Songer, Buchanan, Westin, Hodnick and Gorosh 57 - Reference Dutch and Austin 59 , Reference Krul, Sanou, Swart and Girbes 61 , Reference Molloy, Brady and Maleady 63 , Reference Stagelund, Jans, Nielsen and Wildgaard 66

  5. 5. The lack of a prospective, rigorous, risk, and context-matched model for determining the optimum composition and size of on-site medical team;Reference Chapman, Carmichael and Goode 58

  6. 6. The need to reduce the impact of MPEs on local ambulance availability and community acute health infrastructure;Reference Kemp 68 , Reference Lund, Turris and Bowles 69 and

  7. 7. The need for pre-event planning to integrate the responses of police, security, harm reduction, and health care services.Reference Lund, Turris and Bowles 69

Chain of Survival

A chain of survival for cardiac arrest was introduced in the 1991 emergency cardiovascular care (ECC) guidelines, and in 2015, it was expanded to two chains: one for in-hospital cardiac arrest (IHCA) and the other for out-of-hospital cardiac arrest (OHCA; Figure 1).Reference Cummins, Ornato and Thies 53 The chains address the critical steps, or links in the chain, to optimize survival in the event of cardiac arrest in two different contexts. The authors hypothesize that an adaptation of this framework will provide a practical and conceptual basis for improving the ability to collaboratively address safety, security, health, and emergency response for music festivals.

Figure 1 Chains of Survival, Resuscitation Literature.Reference Cummins, Ornato and Thies 53

In this project, the authors employed an operational lens. The focus was on addressing the health of individuals by integrating all of the siloed teams responsible for providing safety, security, health, and emergency response services on-site and off-site.

Adapting the Existing Model

Based on analysis of the teams involved in music festival safety, security, health, and emergency response services, as well as the elements cited above from academic case reports about music festivals (and the grey literature regarding deaths associated with music festivals), the ECC chain of survival was adapted. Applied to the context of music festivals, the Event Chain of Survival was developed.

Face validity is defined as the ability of a given model or framework to describe or explain what it is supposed to describe or explain. The model was previewed at the World Congress on Disaster and Emergency Medicine 2015 in Cape Town (South Africa)Reference Lund, Turris and Munn 62 and the Mass Gathering Medicine Summit 2016 in New York City, New York (USA), and the authors responded to feedback in subsequent drafts.

Results

The Event Chain of Survival (Figure 2) is a framework that integrates the groups and players that have a role in production, policing, safety, health, and emergency services.Reference Gadsby 70 Pre-event collaboration permits both proactive upstream thinking (ie, appreciating risk or anticipating and preventing illness and injury) and reactive downstream responses (ie, conceptualizing a timely, appropriate, efficient response to emergencies on-site). The six, interdependent links in the Chain include: (1) event producers; (2) police and security; (3) festival health; (4) on-site medical services; (5) ambulance service; and (6) off-site medical services.

Figure 2 Event Chain of Survival for Music Festivals.Reference Gadsby 70

Discussion

Link #1, Event Producers

The event producers are ultimately the hosts, owners, organizers, and/or business people who bring amazing events to communities. Event producers, although they may not be usually considered as part of the health/safety/security context, are ultimately responsible for all aspects of the event, relying on contracted and community partners to ensure professional and safe operations of all aspects of the event. Liability is shared through contractual arrangements for provision of some services on the event. They want to produce a safe, enjoyable event.

To achieve this goal, event producers coordinate, engage, and contract with many different groups. They adhere to industry standards for safe construction, activities that mitigate intrinsic risks, signage, fencing, lighting, potable water, sanitation, waivers, communication, and contractor relationships. Their actions are most powerful pre-event. Event producers bring a “business” focus to the Event Chain of Survival, considering what is profitable, reasonable, and sustainable. There is little published evidence in the medical literature regarding the impact of interventions and decisions that event producers make on morbidity and mortality.

Link #2, Police and Security

Police officers and security services are contracted by the event producer. Access, egress, ports of entry, vehicles and traffic, weapons, drugs, contraband, behavior control, crowd management, incident response, incident investigation, and a visible presence as a preventative measure are all areas of interest for these teams. They screen, confiscate, control, enforce, interface, respond, communicate, educate, grant amnesty, help, and protect festival attendees.

Police and security may reduce mortality and morbidity at music festivals by modulating some crowd behavior, limiting influx of some risky items and individuals, managing crowd movement, and (if required) mounting an emergency response. Police and security services contain, minimize, reduce exposures, and remove (if identified) individuals selling potentially harmful drugs at festivals. Their actions are most powerful during an event and they bring an “enforcement” focus to security, safety, health, and emergency response interventions that will protect the public and respect the law. There is conflicting evidence regarding the impact of some police and security interventions intended to reduce morbidity and mortality (eg, amnesty bins, drug-sniffer dogs, and strong security and police presence at festival entry points). For example, there is some concern that with interventions such as gate searches, patrons will consume substances more rapidly, or in greater quantity, than originally planned prior to entering the event to avoid confiscation by front-line security and policing services (a.k.a. front-loading or “tail-gating”).

Link #3, Festival Health

A variety of community groups are captured in this link, each team characterized by one or more of the following functions: peer support, health promotion, illness/injury prevention, and harm reduction. These teams are invested in health and safety. Some of these groups are peer-driven and represent the attendees as an important component of the Event Chain of Survival. They educate, promote, listen, engage, prevent, reduce, divert, and act as a catalyst for change. Some take a position of non-judgmental support around risk-taking behaviors.

Through a multitude of actions ranging from making sure there is free potable water and access to shade on-site, to peer and expert education about recreational drugs and “trip sitting,” these teams aim to reduce the number of bad outcomes at music festivals. Their actions are most powerful during a MPE, although ideally creating an environment that supports health and healthy behaviors begins in the planning stages of a music festival and requires that professionals, who usually work in silos, collaborate. The festival health team brings a “harm-reduction” focus to event production. There is little empiric evidence with regard to the effects of harm reduction and prevention efforts in the setting of music festivals, though the anecdotal support for these services is compelling and demands further investigation.

Link #4, On-Site Medical Services

Although not required by law in most North American jurisdictions, music festivals (to varying degrees) have on-site medical teams. These teams may provide anything from a first aid, prehospital-driven deployment to an advanced, multi-disciplinary level of care response that includes prehospital providers, physicians, nurses, and others. Contracted, volunteer, and/or blended models have been described. On-site medical teams plan, prevent, communicate, respond, diagnose, and treat ill and injured attendees. This team reduces morbidity and mortality on-site through the provision of timely care for a full spectrum of health presentations from minor to critical interventions that save lives.

On-site medical teams mitigate community impact by decreasing the need to transfer patients into the community by maximizing appropriate care on-site.Reference Lund and Turris 2 , Reference Bledsoe, Songer, Buchanan, Westin, Hodnick and Gorosh 57 - Reference Dutch and Austin 59 , Reference Krul, Sanou, Swart and Girbes 61 , Reference Molloy, Brady and Maleady 63 , Reference Stagelund, Jans, Nielsen and Wildgaard 66 Non-ambulance transports to hospital (ie, shuttles), when appropriate, preserve ambulance resources for patients requiring active care or supine position during transport. The actions of the on-site medical team are most powerful in pre-event coordination and on-event response through direct patient care. This team brings a “health care and emergency response” focus to events, considering how best to support individuals after they become ill or injured.

Link #5, Ambulance Services

Contracted and/or community ambulance services are staffed by trained paramedics. This link in the Event Chain of Survival addresses attendees requiring a transfer for hospital-based care when acuity or needs for investigations and/or definitive care exceed the capacity of on-site care and monitoring. This link incorporates pre-engagement and planning for ambulance transfer services. In some jurisdictions, contracted ambulance companies may also participate in the provision of on-site care (Link #4).

Traditionally, ambulance services respond to and stabilize patients with a default intention of transporting them to definitive care, such as an emergency department (ED). More recently, a shift is occurring and there is increased discussion that paramedic training should evolve to support a “treat and release” model.Reference Evans, McGovern, Birch and Newbury-Birch 71 - Reference Finn, Fatovich and Arendts 73 When able to transport to an appropriate on-site event team in a collaborative model, on-site paramedics may defer hospital transfer, delay it until timely for the receiving institution, or facilitate non-ambulance transfer (ie, shuttle). Paramedics respond, assess, transport, treat, and communicate and liaise with on-site medical teams and local hospitals. When the rate of transport is predictably high, pre-contracting standby ambulance services helps to preserve baseline prehospital services in the host community by not unduly drawing community resources to the event site. They bring both a “disaster response” and “health care and emergency response” focus to event planning. There is currently no published model for determining the optimum size and composition of an ambulance service response for music festivals.

Link #6, Off-Site Medical Services

Community health care services capture a broad range of groups external to music festivals that have a stake in the health impacts on the populations they serve. Walk-in clinics, EDs, and other services in hospital, diagnostic testing facilities, and poison control are all examples of community health services available to a varying degree, depending on the size of the local community.

These teams receive, assess, investigate, diagnose, treat, prescribe, admit, and discharge. They provide definitive care. However, because the morbidity and mortality resulting from a music festival “coming to town” will directly impact the volume and case mix of patients that present in a given 24 hours, these teams need to be engaged early in the planning phase of an event. Pre-engagement with community health stakeholders may ensure adequate coverage for anticipated volume, and/or may prevent reactionary over-planning based on assumptions about services (or lack thereof) on the event site. Case reports are the primary form of evidence about the impact of MPEs on local community health infrastructure.

Balancing Proaction and Reaction

The six links in the chain divide naturally into proactive and reactive halves. Although all six links may collaboratively plan and contribute to prevention, the first three links have a primary focus on the prevention of morbidity and mortality. Links four through six represent the reaction phase, attempting to minimize morbidity and mortality after an injury or illness presentation has already occurred. The framework presented above, in common with the original chain of survival, addresses many themes discussed in the literature review. The main point of difference is the introduction of a proactive focus. The focus on integration, health promotion, illness prevention, and harm reduction are thought to be essential to reducing harms occurring at music festivals.

Interdependency of the Links

Each link in the Event Chain of Survival currently operates as a silo (Figure 3).Reference Michele 74 A focus on collaborative planning and a unified approach to policy development in advance of the event, consistent decision making on-event, and transparent post-event debriefing is paramount to minimize morbidity and mortality, and optimize efficiencies. Leaders, staff, and volunteers in the different links often work in a disconnected fashion. Added to this is the fact that members of the various teams are often unknown to each other prior to the event and that each team approaches health and safety planning with a different, unique (albeit overlapping) lens. Getting everyone “on the same page” with regard to philosophies and policies to support practice is vital to support the health and well-being of attendees.

Figure 3 Cultural Silos.Reference Michele 74

Future Directions

The Event Chain of Survival has the potential to provide a framework for research to reduce morbidity and mortality at music festivals. Of note, the overlapping interests and motivations of each team/silo becomes evident in Table 1-2. Such an approach may begin to address the current dearth of research about the many consensus opinions on festival health. As well, in the future, this framework could be adapted to other types of MPEs.

Table 1 Upstream Links

Table 2 Downstream Links

Limitations

Of note, not all of the issues raised in case studies about music festivals were addressed in the adapted framework. The framework, and the blending of proactive and reactive approaches, should be trialed at a series of music festivals. The Event Chain of Survival applies in a Western context and would need to be adapted for use in the developing world. The Event Chain of Survival, as described, may require the addition of local, regional, or national governments when a threat assessment indicates a higher level of risk.

Conclusions

The authors have proposed a framework for describing, understanding, and planning around safety, security, health, and emergency services integration for music festivals. This framework is based on the commonly known “chain of survival” discussed in the resuscitation literature. The authors argue that adapting and applying this concept in the context of music festivals provides a comprehensive framework upon which to improve communication and planning at events. It further creates a common structure upon which to build research to demonstrate interventions that may reduce morbidity and mortality at MPEs.

Footnotes

Conflicts of interest: No funding was received for the work presented in this unsolicited paper. Adam Lund regularly engages in volunteer and contracted positions in clinical and medical direction roles at events across Canada. Sheila Turris regularly undertakes volunteer and paid roles at major planned events.

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Figure 0

Figure 1 Chains of Survival, Resuscitation Literature.53

Figure 1

Figure 2 Event Chain of Survival for Music Festivals.70

Figure 2

Figure 3 Cultural Silos.74

Figure 3

Table 1 Upstream Links

Figure 4

Table 2 Downstream Links