Mass gatherings (which may be defined as congregations of more than 1000 persons1) are less common in New Zealand than other parts of the world but in 2011 and 2012, Wellington hosted the quarter finals of the Rugby World Cup 2011 (RWC) as well as the New Zealand rounds of the International Rugby Boards Sevens tournament. Although the medical literature contains papers on healthcare planning for rock concerts, carnivals, sporting and other large events,1-7 the only report we have found relating to healthcare issues at major rugby competitions relates to injuries sustained by competitors.8/These rugby events have attracted a large number of sports fans and revellers to the capital and many required medical attention for minor injuries or illness which were most frequently associated with excessive consumption of alcohol. The Sevens tournament in particular has developed a reputation for fancy dress competitions and revelry.In preparation for these rugby events, prehospital treatment and triage facilities were established in an attempt to ease the strain on the Wellington Free Ambulance Service and the citys ED. This paper reports on the initiative which aimed to improve safety for rugby fans and reduce the burden on health services during these major events.Methods During the Wellington Sevens tournament on 4th and 5th February 2011, triage and treatment facilities (safe zones) were piloted by Wellington Free Ambulance at Westpac Stadium situated adjacent to the city during the day and in the central hospitality zone in the evening. The latter contained a small resuscitation area, camp-beds and a cushioned mat for intoxicated patients, and a table and chairs for the management of ambulatory patients. The facility remained open overnight until 0500 hours and was staffed by event medics (first-aiders) and paramedics, supported by one Emergency Department doctor. The arrangement was repeated at the Rugby World Cup quarter final weekend of 8th and 9th October 2011 and during the International Sevens weekend of 3rd and 4th February 2012. Potential patients either presented to the safe zone or were identified by police and radio-equipped patrols of event medics who transported them by carry chair or stretcher. There were no established exclusion criteria. On arrival, they were assessed and treated by the event medics and paramedics. For the RWC quarter final weekend and the 2011 and 2012 Sevens weekends, patients could be referred to the on-site doctor as necessary. Decisions were taken regarding the need for transfer of the patient to the ED but profound intoxication with alcohol was not an automatic indication for hospital transfer. A log of patients seen and treatment given was maintained and a standard ambulance patient report form (PRF) was completed. An intoxication treatment pathway (Fig. 1) was developed in advance of the 2011 Sevens where it was tested. The form was designed for use by event medics and paramedics without on-site medical support. Feedback was received regarding the effectiveness of the pathway and the ability of medics to apply it. In response to the experience gained from the 2011 Sevens, a similar facility was set up every Friday and Saturday night in the citys hospitality zone prior to the RWC and during RWC pool matches. This Safer Cities service was funded by Wellington City Council (WCC), the Accident Compensation Corporation (ACC) and Wellington Free Ambulance (WFA), and was staffed by a small number of event medics and paramedics with no on-site medical support. It prompted the development of a questionnaire (Fig. 2) intended to collect information on the drinking habits of those attending the centre. This questionnaire was designed following input from various groups (WCC, ACC, WFA, NZ Police, NZ Alcohol Advisory Council) and was employed at subsequent RWC events and the 2012 Sevens. It was used in conjunction with an alcohol advice pack supplied to intoxicated patients or their escorts on departure. The effectiveness of the service was assessed by incorporating into the Safer Cities Form a statement asking paramedics whether in the absence of the centre, they believed that the patient would have had to be transferred by emergency ambulance to the ED. This question was answered by recording Yes , Likely , Unlikely or No on the safer cities form (Fig. 2). Each case was discussed with an experienced paramedic to ensure that the need for patient transfer to ED in the absence of a safe zone was correctly judged. Measuring ED avoidance in this way was considered superior to assessing any impact within the ED as background attendances for conditions unrelated to the rugby event would be difficult to quantify, especially in view of the temporary increase in the local population. Figure 1. Alcohol intoxication pathway Figure 2. Safer cities form Results Wellington International Sevens 2011 The initial findings of this study, documented at the 2011 Wellington Sevens, are summarised in Table 1. The average age of patients seen was 25 years. Significantly more patients attended the stadium area than the hospitality zone which functioned for a shorter period of time. Of the total of 73 patients treated, 27 were thought to be dehydrated in association with the hot weather and alcohol consumption and were given intravenous saline. Three also received intravenous glucose. Only 19 of 73 (26%) patients needed to be transported to the ED, achieving a significant reduction in the number of patients who would have been transferred there by ambulance staff in the absence of a triage facility. It is noteworthy that all injured patients seen in the hospitality zone had presented with wounds sustained on broken glass, mainly involving the feet. Many revellers went barefoot in response to the warm temperature and the desire to remove fancy dress. This was unfortunate as some areas were covered by broken drinking glass. Patients with glass injury were not directed immediately to the ED but after careful inspection, cleaning, and dressing of their wounds, they were instructed to attend a local ED or general practitioner during normal hours the next working day for clinical review and radiology to exclude retained glass. Table 1. Wellington International Sevens 2011 Variables Stadium Area Hospitality Zone Duration of service (hours) Patients seen & treated Intravenous fluid required Intravenous glucose given Patients transported to the ED Glass injuries 14 63 24 3 16/63 (25%) 0 7 10 3 0 3/10 (30%) 10 Rugby World Cup 2011 A number of RWC pool matches were held in Wellington but the busiest weekend was that of 8th-9th October when four test matches were held at the stadium. Patient details are summarised in Table 2. On the two quarter final days, a total of 35 patients were seen in the triage and treatment facility in the hospitality zone. Sixty percent were male and the average age was 29. Most were New Zealanders and none had attended the match. The average treatment time was 57 mins and the most common diagnoses were alcohol-related in 28 (80%), with intoxication being the primary diagnosis in 16 (46%). All except one of the intoxicated patients were rehydrated with intravenous saline to which glucose was added in most cases. 100ml of 10% dextrose was given if the blood glucose was less than 10mmol/L. Alcohol-related injuries occurred in 10 attendees (29%). Only six (17%) of patients required direct referral to the ED and all but one were transported by ambulance. One patient was transported because the facility had to close at 0500 hours. Event medic and paramedic staff considered that two-thirds of the patients seen would have, or were likely to have been transferred to the ED by emergency ambulance if no safe zone had been available. Wellington International Sevens 2012 The findings made at the 2012 Wellington Sevens are also summarised in Table 2. The average age of patients seen was 25 years at the stadium during the day but slightly younger patients were seen in the hospitality zone in the evenings. As at the 2011 Sevens, significantly more patients attended the stadium area than the hospitality zone which functioned for one night only. Table 2. Rugby World Cup (RWC) 2011 and 2012 Sevens RWC Hosp. Zone 2012 SEVENS Stadium Hosp. Zone No. of patients 35 64 22 Male:Female (% male) 21:14 (60%) 25:39 (39%) 11:11 (50%) Age (average) 17-68 (29) 17-65 (25.9) 15-31 (20.35) Nationality: New Zealander International Not Recorded 16 (45.7%) 13 (37.1%) 6 (17.1%) New Zealander UK European Maori Pacific Other 38 (59.4%) 17 (26.6%) 3 (4.7%) 3 (4.7%) 2 (3.1%) 1 (1.6%) 17 (77%) 3 (13.6%) 1 (4.5%) 1 (4.5%) Occupation: Employed Students Unemployed Not Recorded 11 (31.4%) 11 (31.4%) 2 (5.7%) 11 (31.4%) Employed Students Not Recorded 19 (29.7%) 17 (26.6%) 28 (43.8%) 11 (50%) 5 (22.7%) 6 (27.3%) Treatment times (average) 9 m\u20133h 5m (57 mins) 2m\u20134h15 (1h 1min) 19 m\u20131h15m (54 mins) Alcohol involved 28 (80%) 54 (84.3%) 20 (90.1%) Diagnoses*: Intoxication Trauma Assault Medical 16 (45.7%) 10 (28.6%) 2 (5.7%) 8 (22.9%) Intoxication Trauma Assault Medical Glass injuries 46 (71.9%) 23 (35.9%) 1 (1.6%) 5 (7.8%) 1 (1.6%) 6 (27.3%) 12 (54.5%) 3 (13.6%) 4 (18%) 5 (22.7%) Given IV fluid 15 (42.9%) 11 (17.2%) 6 (27.3%) Given IV glucose 14 (40%) 11 (17.2%) 6 (27.3%) Direct ED Transfer 6 (17.1%) 5 (7.8%) 0 To ED if no facility: Yes Likely Unlikely No 11 (31.4%) 12 (34.3%) 10 (28.6%) 2 (5.7%) Yes Likely Unlikely No 20 (31.2%) 13 (20.3%) 22 (34.3%) 9 (14.1%) 8 (36.4%) 6 (27.3%) 3 (13.6%) 5 (22.7%) (*Some patients had more than one diagnosis, e.g. intoxication and head injury) Of the total of 86 patients treated, 17 were sufficiently intoxicated and dehydrated by the warm weather to require intravenous saline, supplemented with a small dose of intravenous dextrose. Only five of 86 patients (5.8%) needed to be transported to the ED, a further reduction on the figures for 2011. Paramedics determined that 47 of the 86 patients (54.7%) would have, or were likely to have required direct transfer to the ED in the absence of a safe zone. In 2012, six injuries were sustained on broken glass (7% of patients), all but one in the hospitality zone. This was an improvement on the previous year. Once again, these patients were not directed immediately to the ED but after careful inspection, cleaning and dressing of their wounds, were instructed to attend a local ED or general practitioner during normal hours the next working day for clinical review and radiology to exclude retained glass. Shivering had been frequently observed in patients who received intravenous fluid at ambient temperature at the RWC, despite the use of double blankets. At the 2012 Sevens, bags of intravenous crystalloid were therefore warmed briefly in a microwave and stored in a temperature-monitored insulated box prior to administration. This course of action resulted in a marked reduction in shivering or complaints from patients of feeling cold. Cost implications Table 3 summarises the balance of expenditure and savings associated with the RWC and 2012 initiatives. In principle, the cost of consumables to the ambulance service can be balanced against a corresponding reduction in the cost of ED consumables. The hire charge for temporary facilities at the stadium and hospitality zones (exhibition trucks), together with staff allowances and salaries for non-volunteer staff, are easily offset by the cost of ambulance provision for patients who wo

Mass gatherings (which may be defined as congregations of more than 1000 persons1) are less common in New Zealand than other parts of the world but in 2011 and 2012, Wellington hosted the quarter finals of the Rugby World Cup 2011 (RWC) as well as the New Zealand rounds of the International Rugby Boards Sevens tournament. Although the medical literature contains papers on healthcare planning for rock concerts, carnivals, sporting and other large events,1-7 the only report we have found relating to healthcare issues at major rugby competitions relates to injuries sustained by competitors.8/These rugby events have attracted a large number of sports fans and revellers to the capital and many required medical attention for minor injuries or illness which were most frequently associated with excessive consumption of alcohol. The Sevens tournament in particular has developed a reputation for fancy dress competitions and revelry.In preparation for these rugby events, prehospital treatment and triage facilities were established in an attempt to ease the strain on the Wellington Free Ambulance Service and the citys ED. This paper reports on the initiative which aimed to improve safety for rugby fans and reduce the burden on health services during these major events.Methods During the Wellington Sevens tournament on 4th and 5th February 2011, triage and treatment facilities (safe zones) were piloted by Wellington Free Ambulance at Westpac Stadium situated adjacent to the city during the day and in the central hospitality zone in the evening. The latter contained a small resuscitation area, camp-beds and a cushioned mat for intoxicated patients, and a table and chairs for the management of ambulatory patients. The facility remained open overnight until 0500 hours and was staffed by event medics (first-aiders) and paramedics, supported by one Emergency Department doctor. The arrangement was repeated at the Rugby World Cup quarter final weekend of 8th and 9th October 2011 and during the International Sevens weekend of 3rd and 4th February 2012. Potential patients either presented to the safe zone or were identified by police and radio-equipped patrols of event medics who transported them by carry chair or stretcher. There were no established exclusion criteria. On arrival, they were assessed and treated by the event medics and paramedics. For the RWC quarter final weekend and the 2011 and 2012 Sevens weekends, patients could be referred to the on-site doctor as necessary. Decisions were taken regarding the need for transfer of the patient to the ED but profound intoxication with alcohol was not an automatic indication for hospital transfer. A log of patients seen and treatment given was maintained and a standard ambulance patient report form (PRF) was completed. An intoxication treatment pathway (Fig. 1) was developed in advance of the 2011 Sevens where it was tested. The form was designed for use by event medics and paramedics without on-site medical support. Feedback was received regarding the effectiveness of the pathway and the ability of medics to apply it. In response to the experience gained from the 2011 Sevens, a similar facility was set up every Friday and Saturday night in the citys hospitality zone prior to the RWC and during RWC pool matches. This Safer Cities service was funded by Wellington City Council (WCC), the Accident Compensation Corporation (ACC) and Wellington Free Ambulance (WFA), and was staffed by a small number of event medics and paramedics with no on-site medical support. It prompted the development of a questionnaire (Fig. 2) intended to collect information on the drinking habits of those attending the centre. This questionnaire was designed following input from various groups (WCC, ACC, WFA, NZ Police, NZ Alcohol Advisory Council) and was employed at subsequent RWC events and the 2012 Sevens. It was used in conjunction with an alcohol advice pack supplied to intoxicated patients or their escorts on departure. The effectiveness of the service was assessed by incorporating into the Safer Cities Form a statement asking paramedics whether in the absence of the centre, they believed that the patient would have had to be transferred by emergency ambulance to the ED. This question was answered by recording Yes , Likely , Unlikely or No on the safer cities form (Fig. 2). Each case was discussed with an experienced paramedic to ensure that the need for patient transfer to ED in the absence of a safe zone was correctly judged. Measuring ED avoidance in this way was considered superior to assessing any impact within the ED as background attendances for conditions unrelated to the rugby event would be difficult to quantify, especially in view of the temporary increase in the local population. Figure 1. Alcohol intoxication pathway Figure 2. Safer cities form Results Wellington International Sevens 2011 The initial findings of this study, documented at the 2011 Wellington Sevens, are summarised in Table 1. The average age of patients seen was 25 years. Significantly more patients attended the stadium area than the hospitality zone which functioned for a shorter period of time. Of the total of 73 patients treated, 27 were thought to be dehydrated in association with the hot weather and alcohol consumption and were given intravenous saline. Three also received intravenous glucose. Only 19 of 73 (26%) patients needed to be transported to the ED, achieving a significant reduction in the number of patients who would have been transferred there by ambulance staff in the absence of a triage facility. It is noteworthy that all injured patients seen in the hospitality zone had presented with wounds sustained on broken glass, mainly involving the feet. Many revellers went barefoot in response to the warm temperature and the desire to remove fancy dress. This was unfortunate as some areas were covered by broken drinking glass. Patients with glass injury were not directed immediately to the ED but after careful inspection, cleaning, and dressing of their wounds, they were instructed to attend a local ED or general practitioner during normal hours the next working day for clinical review and radiology to exclude retained glass. Table 1. Wellington International Sevens 2011 Variables Stadium Area Hospitality Zone Duration of service (hours) Patients seen & treated Intravenous fluid required Intravenous glucose given Patients transported to the ED Glass injuries 14 63 24 3 16/63 (25%) 0 7 10 3 0 3/10 (30%) 10 Rugby World Cup 2011 A number of RWC pool matches were held in Wellington but the busiest weekend was that of 8th-9th October when four test matches were held at the stadium. Patient details are summarised in Table 2. On the two quarter final days, a total of 35 patients were seen in the triage and treatment facility in the hospitality zone. Sixty percent were male and the average age was 29. Most were New Zealanders and none had attended the match. The average treatment time was 57 mins and the most common diagnoses were alcohol-related in 28 (80%), with intoxication being the primary diagnosis in 16 (46%). All except one of the intoxicated patients were rehydrated with intravenous saline to which glucose was added in most cases. 100ml of 10% dextrose was given if the blood glucose was less than 10mmol/L. Alcohol-related injuries occurred in 10 attendees (29%). Only six (17%) of patients required direct referral to the ED and all but one were transported by ambulance. One patient was transported because the facility had to close at 0500 hours. Event medic and paramedic staff considered that two-thirds of the patients seen would have, or were likely to have been transferred to the ED by emergency ambulance if no safe zone had been available. Wellington International Sevens 2012 The findings made at the 2012 Wellington Sevens are also summarised in Table 2. The average age of patients seen was 25 years at the stadium during the day but slightly younger patients were seen in the hospitality zone in the evenings. As at the 2011 Sevens, significantly more patients attended the stadium area than the hospitality zone which functioned for one night only. Table 2. Rugby World Cup (RWC) 2011 and 2012 Sevens RWC Hosp. Zone 2012 SEVENS Stadium Hosp. Zone No. of patients 35 64 22 Male:Female (% male) 21:14 (60%) 25:39 (39%) 11:11 (50%) Age (average) 17-68 (29) 17-65 (25.9) 15-31 (20.35) Nationality: New Zealander International Not Recorded 16 (45.7%) 13 (37.1%) 6 (17.1%) New Zealander UK European Maori Pacific Other 38 (59.4%) 17 (26.6%) 3 (4.7%) 3 (4.7%) 2 (3.1%) 1 (1.6%) 17 (77%) 3 (13.6%) 1 (4.5%) 1 (4.5%) Occupation: Employed Students Unemployed Not Recorded 11 (31.4%) 11 (31.4%) 2 (5.7%) 11 (31.4%) Employed Students Not Recorded 19 (29.7%) 17 (26.6%) 28 (43.8%) 11 (50%) 5 (22.7%) 6 (27.3%) Treatment times (average) 9 m\u20133h 5m (57 mins) 2m\u20134h15 (1h 1min) 19 m\u20131h15m (54 mins) Alcohol involved 28 (80%) 54 (84.3%) 20 (90.1%) Diagnoses*: Intoxication Trauma Assault Medical 16 (45.7%) 10 (28.6%) 2 (5.7%) 8 (22.9%) Intoxication Trauma Assault Medical Glass injuries 46 (71.9%) 23 (35.9%) 1 (1.6%) 5 (7.8%) 1 (1.6%) 6 (27.3%) 12 (54.5%) 3 (13.6%) 4 (18%) 5 (22.7%) Given IV fluid 15 (42.9%) 11 (17.2%) 6 (27.3%) Given IV glucose 14 (40%) 11 (17.2%) 6 (27.3%) Direct ED Transfer 6 (17.1%) 5 (7.8%) 0 To ED if no facility: Yes Likely Unlikely No 11 (31.4%) 12 (34.3%) 10 (28.6%) 2 (5.7%) Yes Likely Unlikely No 20 (31.2%) 13 (20.3%) 22 (34.3%) 9 (14.1%) 8 (36.4%) 6 (27.3%) 3 (13.6%) 5 (22.7%) (*Some patients had more than one diagnosis, e.g. intoxication and head injury) Of the total of 86 patients treated, 17 were sufficiently intoxicated and dehydrated by the warm weather to require intravenous saline, supplemented with a small dose of intravenous dextrose. Only five of 86 patients (5.8%) needed to be transported to the ED, a further reduction on the figures for 2011. Paramedics determined that 47 of the 86 patients (54.7%) would have, or were likely to have required direct transfer to the ED in the absence of a safe zone. In 2012, six injuries were sustained on broken glass (7% of patients), all but one in the hospitality zone. This was an improvement on the previous year. Once again, these patients were not directed immediately to the ED but after careful inspection, cleaning and dressing of their wounds, were instructed to attend a local ED or general practitioner during normal hours the next working day for clinical review and radiology to exclude retained glass. Shivering had been frequently observed in patients who received intravenous fluid at ambient temperature at the RWC, despite the use of double blankets. At the 2012 Sevens, bags of intravenous crystalloid were therefore warmed briefly in a microwave and stored in a temperature-monitored insulated box prior to administration. This course of action resulted in a marked reduction in shivering or complaints from patients of feeling cold. Cost implications Table 3 summarises the balance of expenditure and savings associated with the RWC and 2012 initiatives. In principle, the cost of consumables to the ambulance service can be balanced against a corresponding reduction in the cost of ED consumables. The hire charge for temporary facilities at the stadium and hospitality zones (exhibition trucks), together with staff allowances and salaries for non-volunteer staff, are easily offset by the cost of ambulance provision for patients who wo