Hostname: page-component-745bb68f8f-l4dxg Total loading time: 0 Render date: 2025-02-06T09:17:38.378Z Has data issue: false hasContentIssue false
  • English
  • Français

Health Service Impact from Mass Gatherings: A Systematic Literature Review

Published online by Cambridge University Press:  12 December 2016

Jamie Ranse ,
Alison Hutton ,
Toby Keene ,
Shane Lenson ,
Matt Luther ,
Nerolie Bost ,
Amy N. B. Johnston ,
Julia Crilly ,
Matt Cannon  and
Nicole Jones
...Show all authors
Jamie Ranse*
Affiliation:
University of Canberra, Faculty of Health, Canberra, Australian Capital Territory, Australia Flinders University, School of Nursing and Midwifery, Adelaide, South Australia, Australia St John Ambulance Australia (New South Wales), Event Health Services, Sydney, New South Wales, Australia
Alison Hutton
Affiliation:
Flinders University, School of Nursing and Midwifery, Adelaide, South Australia, Australia
Toby Keene
Affiliation:
Australian Catholic University, Canberra, Australian Capital Territory, Australia Australian Capital Territory Ambulance Service, Canberra, Australian Capital Territory, Australia
Shane Lenson
Affiliation:
Australian Catholic University, Canberra, Australian Capital Territory, Australia
Matt Luther
Affiliation:
Calvary Health Care ACT, Canberra, Australian Capital Territory, Australia
Nerolie Bost
Affiliation:
Department of Emergency Medicine, Gold Coast Health, Southport, Queensland, Australia Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
Amy N. B. Johnston
Affiliation:
Department of Emergency Medicine, Gold Coast Health, Southport, Queensland, Australia Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
Julia Crilly
Affiliation:
Department of Emergency Medicine, Gold Coast Health, Southport, Queensland, Australia Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
Matt Cannon
Affiliation:
St John Ambulance Australia (New South Wales), Event Health Services, Sydney, New South Wales, Australia
Nicole Jones
Affiliation:
University of Canberra, Faculty of Health, Canberra, Australian Capital Territory, Australia Canberra Hospital, Intensive Care Unit, Canberra, Australian Capital Territory, Australia
Courtney Hayes
Affiliation:
University of Canberra, Faculty of Health, Canberra, Australian Capital Territory, Australia
Brandon Burke
Affiliation:
Canberra Hospital, Intensive Care Unit, Canberra, Australian Capital Territory, Australia Medical School, The Australian National University, Canberra, Australian Capital Territory, Australia
*
Correspondence: Jamie Ranse, RN, FACN, FCENA, BNurs University of Canberra University Drive Bruce, Australian Capital Territory 2617 Australia E-mail: jamie@jamieranse.com
Rights & Permissions [Opens in a new window]

Abstract

Background

During a mass gathering, some participants may receive health care for injuries or illnesses that occur during the event. In-event first responders provide initial assessment and management at the event. However, when further definitive care is required, municipal ambulance services provide additional assessment, treatment, and transport of participants to acute care settings, such as hospitals. The impact on both ambulance services and hospitals from mass-gathering events is the focus of this literature review.

Aim

This literature review aimed to develop an understanding of the impact of mass gatherings on local health services, specifically pertaining to in-event and external health services.

Method

This research used a systematic literature review methodology. Electronic databases were searched to find articles related to the aim of the review. Articles focused on mass-gathering health, provision of in-event health services, ambulance service transportation, and hospital utilization.

Results

Twenty-four studies were identified for inclusion in this review. These studies were all case-study-based and retrospective in design. The majority of studies (n=23) provided details of in-event first responder services. There was variation noted in reporting of the number and type of in-event health professional services at mass gatherings. All articles reported that patients were transported to hospital by the ambulance service. Only nine articles reported on patients presenting to hospital. However, details pertaining to the impact on ambulance and hospital services were not reported.

Conclusions

There is minimal research focusing on the impact of mass gatherings on in-event and external health services, such as ambulance services and hospitals. A recommendation for future mass-gathering research and evaluation is to link patient-level data from in-event mass gatherings to external health services. This type of study design would provide information regarding the impact on health services from a mass gathering to more accurately inform future health planning for mass gatherings across the health care continuum.

RanseJ, HuttonA, KeeneT, LensonS, LutherM, BostN, JohnstonANB, CrillyJ, CannonM, JonesN, HayesC, BurkeB. Health Service Impact from Mass Gatherings: A Systematic Literature Review. Prehosp Disaster Med. 2017;32(1):71–77.

Keywords

Emergency Medical Servicesemergency roomshospitalsmass gatheringparamedicplanned event
Type
Comprehensive Reviews
Information
Prehospital and Disaster Medicine , Volume 32 , Issue 1 , February 2017 , pp. 71 - 77
Copyright
© World Association for Disaster and Emergency Medicine 2016 

Introduction

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, such as a sporting event, music festival, or agricultural show.Reference Ranse, Hutton, Keene, Lenson, Luther, Bost, Johnston, Crilly, Cannon, Jones, Hayes and Burke 1 From a health delivery perspective, ArbonReference Zeitz, Schneider, Jarrett and Zeitz 2 defined a mass gathering as an event “where there is the potential for a delayed response to [health] emergencies because of limited access to patients or other features of the environment and location.” Health services often are provided to participants of a mass gathering by a combination of in-event health services (eg, first aid or medical tent within the event boundaries) and external health services (eg, ambulance services and local hospitals) within a tiered hierarchy of clinical capacity (Figure 1).Reference Arbon 3

Figure 1 Hierarchy of Clinical Care at Mass Gatherings (Modified from Lund, et al; 2014).

First responders at mass gatherings provide in-event health services at a first aid level of patient assessment and management. First responders have additional first aid training and experience when compared to a lay person. The workload of first responders reported in the literature frequently is represented as a patient presentation rate (PPR).Reference Lund, Turris and Bowles 4 The majority of mass-gathering participants who present for clinical assessment and/or management to dedicated first responders have minor injuries or illnesses and commonly return to the event.Reference Arbon 5 On occasion, patients may be referred to in-event health professionals, such as doctors, nurses, and/or paramedics who can provide a higher level of in-event health care.

When the volume of patient presentations or patient acuity exceeds the capability of the in-event health services, there is a reliance on local health community resources external to the mass gathering. Patients may require clinical assessment, management, and transportation by paramedics of the local Emergency Medical Services (EMS) or ambulance service to an acute care facility.Reference Hutton, Ranse and Verdonk 6 The transport to hospital rate (TTHR) specific to a mass gathering represents the workload of ambulance services from a mass gathering.Reference Meites and Brown 7 , Reference Ranse and Hutton 8 If patient transport is required from a mass gathering, the local hospitals are the most likely destination for this definitive care. Mass-gathering participants also may attend a local hospital by using transport other than an ambulance service, such as a private car or public transport. The referral of participants to hospitals from a mass gathering is reported as a referral to hospital rate (RTHR).Reference Meites and Brown 7

Overall, in-event health services aim to maximize the efficiency in responding to health emergencies at a mass gathering, while minimizing the disruption to the normal operational capacity of the external health services in the surrounding community, including the EMS or ambulance service and hospital services.Reference Arbon 3 , Reference Meites and Brown 7 , Reference Ranse, Hutton, Turris and Lund 9 By their nature, mass gathering are unusual events in that patients from these events may place an unusual or excessive demand on community health services. However, the impact on external health services from mass gatherings is not well understood.

Aim

This literature review aimed to develop an understanding of the impact on health services from mass gatherings pertaining to in-event and external health services. This research will provide a valuable step in the broader agenda of mass-gathering health service planning, health service provision, health workforce appropriateness, and health service impact. The research question for this systematic review was: What is the impact of a mass gathering on in-event and external acute health services, such as ambulance services and hospitals?

Methods

Design

A systematic literature review design based on the Preferred Reporting Items of Systematic reviews and Meta-Analysis (PRISMA) guidelinesReference Turris, Lund and Hutton 10 was conducted to answer the research question.

Search Strategy and Data Collection

Databases and search engines, including OvidSP (Ovid Technologies; New York, New York USA; MEDLINE [Medline Industries, Inc.; Mundelein, Illinois USA]; PsycINFO [American Psychological Association; Washington DC, USA]; and DARE [Rutgers University Libraries; New Brunswick, New Jersey USA]), CINAHL (EBSCO Information Services; Ipswich, Massachusetts USA); Pubmed (National Center for Biotechnology Information; Bethesda, Maryland USA); and Scopus (Elsevier; Amsterdam, Netherlands) were used for this review. The search strategy included different combinations of Medical Subject Headings (MeSH) terms and keywords that were relevant to mass gatherings, EMS/ambulance services, and hospitals. All keywords are outlined in Table 1.

Table 1 Search Terms

Note: “OR:” will be used to combine keywords in the same column; “AND:” will be used to include keywords between columns.

In addition to the search strategy used above, manuscripts were obtained directly from the journal Prehospital and Disaster Medicine (PDM; Madison, Wisconsin USA). The journal PDM is known to have numerous publications relating to mass-gathering health.Reference Ranse and Hutton 8 The table of contents for each issue of PDM was screened for papers relating to mass gatherings. Specific inclusion and exclusion criteria were applied to determine the appropriateness of each manuscript to answer the review question (Table 2).

Table 2 Inclusion and Exclusion Criteria

Data Analysis

Information extracted from each paper was entered into a Microsoft Word 2010 table (Microsoft Corporation; Redmond, Washington USA). This information included: author(s), year of publication, country where the mass gathering took place, type of mass-gathering event, reported PPR, if in-event health professionals were present, reported TTHR, and reported RTHR.

Results

In total, 24 studies met the criteria for inclusion (Figure 2). Data extracted to inform this literature review are displayed in Table 3.Reference Liberati, Altman and Tetzlaff 11 - Reference Lund, Turris and Wang 33

Figure 2 PRISMA Flow Diagram.Reference Turris, Lund and Hutton 10

Table 3 Reviewed Manuscripts

Abbreviations: PPR, patient presentation rate; RTHR, referred to hospital rate; TTHR, transport to hospital rate.

a This variable was not reported by the authors.

b A raw number was presented by the authors as a total number of people, rather than presenting a rate.

In-event Health Services

The majority of studies (n=23; 96%) included in this review discussed patient presentations to in-event first responders. Of these, 13 reported the PPR, which ranged between 0.013/1,000 and 198.93/1,000. The remaining 11 studies reported the raw number of patient presentations rather than a rate. The majority of the studies (n=22; 92%) stated that in-event health professionals were present at the mass gathering. However, there was variation in the reporting of the number and type of health professionals. Broadly, health professionals included Medical Officers, Nurses, Nurse Practitioners, Physiotherapists, and Paramedics.

External Health Services

All studies included in this review reported that some patients required transfer by ambulance to hospital. Of these, most (n=16; 67%) studies reported this as a raw number. The remaining (n=8; 33%) studies reported the TTHR, which varied between 0.0035/1,000 and 0.99/1,000. In terms of hospital services impact, less than one-half of studies (n=9; 38%) included the number of patients presenting to hospital. Only one study reported the number of patients presenting to hospital as an RTHR (n=1; 4.5%); one study was unclear about the actual numbers of patients presenting to hospital (n=1; 4.5%); and the remaining (n=7; 29%) reported a raw number.

Discussion

This literature review is, as far as the authors are aware, the first to focus exclusively on the impact of mass gatherings on local health services. In particular, this review highlights two aspects of health service provision associated with mass gatherings: the uptake of in-event health services and the impact on external health services.

In-event Health Services

It is well-established that patient presentations to first responders at mass gatherings vary depending on biomedical, environmental, and psychosocial factors.Reference Lund, Turris and Bowles 4 The results from this review, coupled with previous discussions, have shown that reporting PPR rather than raw patient numbers is critical to allow for comparison and meta-analysis in mass-gathering research and evaluation.Reference Meites and Brown 7 , Reference Ranse and Hutton 8 Further, the literature pertaining to first responder in-event health services remains varied in reporting, focusing on single case studies and the characteristics of patient presentations. Reporting only on patient presentations and patient presenting problems lacks the detail required to assess the impact of in-event first responder services adequately at mass gatherings.

The presence of in-event health professionals was mentioned in all studies. However, the explicit detail of the number of health professionals, discipline area, clinical skill level, and duration of the shift scantly was reported. The type of health professionals present may be directly related to the TTHR. The literature pertaining to in-event health professionals requires development to provide insight into the impact of in-event health professionals at mass gatherings, such as the effect of having health professionals at mass gatherings on patient outcomes and ambulance and hospital avoidance. Future datasets for the research and evaluation of in-event health professionals at mass gatherings should contain information such as the number and skill mix of health professionals as well as the clinical interventions they performed. Possible future data points aimed at capturing the impact of health services are outlined in Table 4. Additionally, a description of the clinical governance structures and decision making of in-event health professionals would be useful to compare the health professional contexts between mass gatherings.

Table 4 Potential Patient Data Set and Entry Codes

External Health Services

Variation exists in the literature in the reporting of patient transport to hospital by ambulance paramedics. Some papers reported a transport rate whereas others reported a raw number. It has been suggested previously that the reporting of a TTHR should be represented as the number of attendees who are transported to hospital, from an event by ambulance, as a rate per 1,000 participants.Reference Meites and Brown 7 Beyond the reporting of the number of patients transported to hospital, there exists a lack of detailed case and/or patient-level data reported, pertaining to ambulance transport from mass gatherings. Therefore, the ability to gain insight into the impact on ambulance services from mass gatherings, as currently reported in the literature, remains unclear.

In order to inform the impact on ambulance services, data to be included in future mass-gathering research and evaluation should include on-scene treatment duration, interventions provided by paramedics, and transport duration (Table 4). Additionally, it may be pertinent to report if the ambulances utilized for the mass-gathering response were diverted from normal community operations or if ambulances were allocated specifically for the purpose of the treatment, management, and transportation of mass-gathering participants. Such information would provide a starting point for future event planning with an aim to minimize the diversion of ambulance services from normal community operations as well as planning for emergency department diversion.

Some work has been undertaken to predict patient presentations to hospital emergency departments/emergency rooms (ERs) from the general community population.Reference Sabra, Cabañas, Bedolla and Borgmann 34 , Reference Boyle, Jessup and Crilly 35 However, predicting the patient presentations to ERs as a result of mass gatherings is not yet discussed in the literature. Only nine studies were identified in this literature review that included patient referrals and/or presentations to ERs secondary to the mass gathering. This provides some insight into the impact on hospital services from a mass gathering; however, it is not a substantial body of knowledge to enable future planning. As such, future mass-gathering research and evaluation should focus on the actual presentations to hospitals in addition to the currently reported referrals from in-event first responders and health professionals. Furthermore, data could include presenting patient triage category, interventions provided, and patient length of stay. This would provide insight into the ER impact from mass gatherings (Table 4).

Reference to the number of patients admitted to hospital in-patient units was specifically made in one manuscript (from the World Championship Games in Athletics in Helsinki, Finland) where 25 people presented to hospital, with four of these presentations requiring hospital admission.Reference Grissom, Finnoff, Murdock and Culberson 12 To gain a broader understanding of the impact of mass gatherings on hospital services, hospital admission data need to be included. These data could include the patient length of stay in various in-patient units, interventions performed, and patient outcomes from hospitalizations (Table 4). This type of data would provide a more detailed layer of information for future research and evaluation regarding the impact on hospitals from mass gatherings and should be included in future research and evaluation.

Limitations

This literature review was restricted to journals published in English. As such, publications in other languages have not been included. Additionally, this literature review only included peer-reviewed literature. As such, non-indexed, or grey literature, was not included in the results of this review. The search terms used in this review were specific. Using additional search terms may have revealed additional publications. Overall, publications from other languages, the non-index literature, and including broader search terms may have produced additional literature and therefore provided further insight into the impact of mass gatherings on health services.

Conclusion

The international mass-gathering literature on the health service impact from mass gatherings focuses on the in-event health services such as PPR to in-event first responder services. There is limited research regarding the understanding of the impact of in-event health professionals’ presence at mass gatherings. Furthermore, the impact on health services external to mass gatherings is reported inconsistently in the literature. Reporting of the requirement of mass gatherings on ambulance services is varied, articulated as either a raw number of patients or as a TTHR, without details of treatment modalities or duration. Additionally, the reporting of hospital presentations is minimal and generally reported as a raw number. Furthermore, the ambulance and hospital presentations reported in the literature do not articulate the financial or workload impact of mass gatherings on these health services. As such, future research and evaluation regarding mass gatherings should include the impact on external health services and report on actual patient presentations, including duration of treatment, interventions performed, and patient outcomes. Linking patient-level data from in-event mass-gathering presentations and treatments to external health services would provide a better understanding of the impact of mass gatherings on ambulance and local hospital services. This information will then guide future health planning for mass gatherings across the health continuum.

References

1. Zeitz, KM, Schneider, DPA, Jarrett, D, Zeitz, CJ. Mass gathering events: retrospective analysis of patient presentations over seven years. Prehosp Disaster Med. 2002;17(3):147-150.CrossRefGoogle ScholarPubMed
2. Arbon, P. Mass-gathering medicine: a review of the evidence and future directions for research. Prehosp Disaster Med. 2007;22(2):131-135.CrossRefGoogle ScholarPubMed
3. Lund, A, Turris, S, Bowles, R, et al. Mass-gathering health research foundational theory: part 1 - population models for mass gatherings. Prehosp Disaster Med. 2014;29(6):648-654.CrossRefGoogle ScholarPubMed
4. Arbon, P. The development of conceptual models for mass-gathering health. Prehosp Disaster Med. 2004;19(3):208-212.CrossRefGoogle ScholarPubMed
5. Hutton, A, Ranse, J, Verdonk, N, et al. Understanding the characteristics of patient presentations of young people at outdoor music festivals. Prehosp Disaster Med. 2014;29(2):160-166.CrossRefGoogle ScholarPubMed
6. Meites, E, Brown, JF. Ambulance need at mass gatherings. Prehosp Disaster Med. 2010;25(6):511-514.CrossRefGoogle ScholarPubMed
7. 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.CrossRefGoogle ScholarPubMed
8. Ranse, J, Hutton, A, Turris, S, Lund, A. Enhancing the minimum data set for mass-gathering research and evaluation: an integrative literature review. Prehosp Disaster Med. 2014;29(3):280-289.CrossRefGoogle ScholarPubMed
9. Turris, SA, Lund, A, Hutton, A, et al. Mass-gathering health research foundational theory: part 2 - event modeling for mass gatherings. Prehosp Disaster Med. 2014;29(6):655-663.CrossRefGoogle ScholarPubMed
10. Liberati, A, Altman, DG, Tetzlaff, J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Ann Intern Med. 2009;151(4):W65-W94.CrossRefGoogle ScholarPubMed
11. Grissom, CK, Finnoff, JT, Murdock, DC, Culberson, JT. Nordic venue medical services during the 2002 Winter Olympics. J Emerg Med. 2006;30(2):203-210.CrossRefGoogle ScholarPubMed
12. Hiltunen, T, Hiltunen, T, Kuisma, M, et al. Prehospital emergency care and medical preparedness for the 2005 World Championship Games in Athletics in Helsinki. Prehosp Disaster Med. 2007;22(4):304-311.CrossRefGoogle ScholarPubMed
13. Yazawa, K, Kamijo, Y, Sakai, R, et al. Medical care for a mass gathering: the Suwa Onbashira Festival. Prehosp Disaster Med. 2007;22(5):431-435.CrossRefGoogle ScholarPubMed
14. Dutch, MJ, Senini, LM, Taylor, DJ. Mass gathering medicine: the Melbourne 2006 Commonwealth Games experience. Emerg Med Australas. 2008;20(3):228-233.CrossRefGoogle ScholarPubMed
15. Nguyen, RB, Milsten, AM, Cushman, JT. Injury patterns and levels of care at a marathon. Prehosp Disaster Med. 2008;23(6):519-525.CrossRefGoogle Scholar
16. Tang, N, Kraus, CK, Brill, JD, et al. Hospital-based event medical support for the Baltimore Marathon, 2002-2005. Prehosp Emerg Care. 2008;12(3):320-326.CrossRefGoogle ScholarPubMed
17. Agar, C, Pickard, L, Bhangu, A. The Tough Guy prehospital experience: patterns of injury at a major UK endurance event. Emerg Med J. 2009;26(11):826-830.CrossRefGoogle Scholar
18. Boeke, PS, House, HR, Graber, MA. Injury incidence and predictors on a multiday recreational bicycle tour: the Register’s Annual Great Bike Ride Across Iowa, 2004 to 2008. Wilderness Environ Med. 2010;21(3):202-207.CrossRefGoogle ScholarPubMed
19. Grant, WD, Nacca, NE, Prince, LA, Scott, JM. Mass-gathering medical care: retrospective analysis of patient presentations over five years at a multi-day mass gathering. Prehosp Disaster Med. 2010;25(2):183-187.CrossRefGoogle Scholar
20. Wood, DM, Beaumont, PO, May, D, Dargan, PI. Recreational drug use presentations during a large outdoor festival event: reduction in hospital emergency department transfer where medical physicians are present. J Subst Use. 2010;15(6):434-441.CrossRefGoogle Scholar
21. Gutman, SJ, Lund, A, Turris, SA. Medical support for the 2009 World Police and Fire Games: a descriptive analysis of a large-scale participation event and its impact. Prehosp Disaster Med. 2011;26(1):33-40.CrossRefGoogle Scholar
22. Jennings, N, Waugh, A, Di Nunzio, J, et al. The Australian FORMULA 1 Grand Prix Medical Centre, Melbourne, March 2011. Australas Emerg Nurs J. 2012;15(2):116-120.CrossRefGoogle Scholar
23. Lyons, N, Jackson, S, Bhangu, A. A summer of cricket: prospective evaluation of all contacts with medical services at Edgbaston cricket ground during summer 2009. Eur J Emerg Med. 2011;18(3):172-175.CrossRefGoogle ScholarPubMed
24. Blank, C, Schamasch, P, Engebretsen, L, et al. Medical services at the first Winter Youth Olympic Games 2012 in Innsbruck/Austria. Br J Sports Med. 2012;46(15):1048-1054.CrossRefGoogle ScholarPubMed
25. Bledsoe, B, Songer, P, Buchanan, K, et al. Burning Man 2011: mass-gathering medical care in an austere environment. Prehosp Emerg Care. 2012;16(4):469-476.CrossRefGoogle Scholar
26. Krul, J, Sanou, B, Swart, EL, Girbes, AR. Medical care at mass gatherings: Emergency Medical Services at large-scale rave events. Prehosp Disaster Med. 2012;27(1):71-74.CrossRefGoogle ScholarPubMed
27. Bortolin, M, Ulla, M, Bono, A, et al. Holy Shroud Exhibition 2010: health services during a 40-day mass-gathering event. Prehosp Disaster Med. 2013;28(3):239-244.CrossRefGoogle ScholarPubMed
28. Locoh-Donou, S, Guofen, Y, Welcher, M, et al. Mass-gathering medicine: a descriptive analysis of a range of mass-gathering event types. Am J Emerg Med. 2013;31(5):843-846.CrossRefGoogle ScholarPubMed
29. McGrath, TM, Yehl, MA. Injury and illness in mountain bicycle stage racing: experience from the Trans-Sylvania Mountain Bike Epic Race. Wilderness Environ Med. 2012;23(4):356-359.CrossRefGoogle ScholarPubMed
30. Pakravan, AH, West, RJ, Hodgkinson, DW. Suffolk Show 2011: prehospital medical coverage in a mass-gathering event. Prehosp Disaster Med. 2013;28(5):529-532.CrossRefGoogle Scholar
31. Williamson, T, Wheeler, P, Stephens, C, Ferguson, M. Emergency care provision at the 2009 Special Olympics Great Britain. Emerg Med J. 2013;30(5):411-413.CrossRefGoogle ScholarPubMed
32. Lund, A, Turris, SA, Wang, P, et al. An analysis of patient presentations at a 2-day mass-participation cycling event: the Ride to Conquer Cancer Case Series, 2010-2012. Prehosp Disaster Med. 2014;29(4):429-436.CrossRefGoogle Scholar
33. Sabra, JP, Cabañas, JG, Bedolla, J, Borgmann, S, et al. Medical support at a large-scale motorsports mass-gathering event: the Inaugural Formula One United States Grand Prix in Austin, Texas. Prehosp Disaster Med. 2014;29(4):392-398.CrossRefGoogle Scholar
34. Boyle, J, Jessup, M, Crilly, J, et al. Predicting emergency department admissions. Emerg Med J. 2012;29(5):358-365.CrossRefGoogle ScholarPubMed
35. Marcilio, I, Hajat, S, Gouveia, N. Forecasting daily emergency department visits using calendar variables and ambient temperature readings. Acad Emerg Med. 2013;20(8):769-777.CrossRefGoogle ScholarPubMed
Figure 0

Figure 1 Hierarchy of Clinical Care at Mass Gatherings (Modified from Lund, et al; 2014).

Figure 1

Table 1 Search Terms

Figure 2

Table 2 Inclusion and Exclusion Criteria

Figure 3

Figure 2 PRISMA Flow Diagram.10

Figure 4

Table 3 Reviewed Manuscripts

Figure 5

Table 4 Potential Patient Data Set and Entry Codes