Mass-gathering medicine (MGM) is a relatively new medical niche with varied definitions.Reference Memish, Steffen and White1 The National Association of Emergency Medical Services Physicians (NAEMSP) initially defined Mass Gathering Events (MGEs) as events with over 1000 attendees.Reference Schwartz, Nafziger and Milsten2 However, it is becoming increasingly recognized that MGEs are much more complex than the number of participants. From a health perspective, this complexity is primarily related to aspects such as the biomedical makeup of the crowd, psychosocial factors like crowd mood and motivation,Reference Hutton, Ranse and Gray3 and environmental characteristics.Reference Hutton, Ranse and Gray4 Currently, the World Health Organization defines an MGE as a planned event that may strain local community resources.5
Several guidelines exist for medical directors of MGEs, including tools for hazard analysis and recommended medical staff ratios.Reference Arbon, Bridgewater and Smith6–Reference Aitsi-Selmi, Murray and Heymann13 However, there is a paucity of research, information, and guidelines for training standards and core competencies of medical staff. Previous studies underscore the desire among emergency medical services personnel for specialized training and skill refinement.Reference Laitano, Pate and Everett14 This is primarily the case, as health care professionals, while competent in their regular daily practice, do not always practice within the MGE context. Additionally, when new to practicing in the MGE context, health professionals may not always consider the complexities of the biomedical, psychosocial, and environmental factors that influence their patient presentations. Furthermore, consideration may not be given to the event’s characteristics, the makeup of the medical team, or other safety and security aspects.Reference Hertelendy, Mobrad and Alhazmi15, Reference Hutton, Ranse and Zimmerman16
As a result, many individual organizations have begun their process for setting the standard in MGM competency training. For example, the American Academy of Event Medicine has responded with a specialized certified event medic program (C-EM).17 Other large-scale events have developed proprietary training programs. These programs demonstrate the MGM community’s recognition of the need for standardized knowledge among medical staff. Many events still utilize volunteer medical staff with diverse capabilities and knowledge, often without prior training or orientation. As in other medicine sectors, specific training focused on specialized care and core competencies promotes better outcomes.Reference Albarqouni, Hoffmann and Straus18, Reference Imanipour, Ebadi and Monadi Ziarat19 However, the evidence to support the type of education and training for MGM is scant.
MGEs have existed for thousands of years.Reference Kraemer20 The focus on improving the health impact and mitigating potential issues has only recently been recognized as a specialized skill.Reference Memish, Steffen and White21 Given the heterogeneity of MGEs, including sporting events, festivals, concerts, and religious gatherings, standards can be challenging to assess and institute. With the vast types of MGM staffing, medical skills can vary greatly, contributing to the incongruity in care and expectations.Reference Arbon22, Reference Parrillo23 The WHO has announced its intention to organize a technical working group of experts to address the establishment of medical standards of care for mass gatherings. The future standards will need to be scalable and adaptable to the various needs associated with specific events.24 With MGM maturing, it is imperative to define training and preparedness standards for all event medical staff. This study aims to define minimum training standards for medical staff at MGEs through expert consensus, addressing the need for structured preparation in this emerging field.
Methods
Design
Following the Guidance on Conducting and Reporting Delphi Studies (CREDES) criteria, this study employed a modified 3-round Delphi methodology. The statements and subsequent rankings were generated online through the STAT59 program, which anonymized all statements and rankings. Consent was obtained verbally and on Stat59 software.
Study participants and recruitment
Study participants were identified as experts in the field of MGM. Experts were recruited during the 5th International Conference for Mass Gatherings (Riyadh, Saudi Arabia, 2023) and the 2023 Mass Gathering Medicine Summit (New York City, USA, 2023). Eligibility requires 3 or more years of experience in MGM, recognized contributions to the field, and previous speaking engagements on MGM due to expertise.
This study was performed electronically via STAT59 (STAT59 Services Ltd., Edmonton, Canada). Twenty-four experts were invited to participate and provided detailed survey explanations via email. This email included the study’s goal to explore the training needs of medical staff at MGEs beyond general first aid principles. This study focused on medical staff, such as Medical Doctors, Doctors of Osteopathy, Nurses, Nurse Practitioners, Physician Assistants, and Paramedics.
Fourteen of the 24 emails responded and signed up for the study in Stat59, with a response rate of 58.3%. The 14 experts provided statements during the first round. Subsequent rounds 2 and 3 had a 64% (9/14) and 57% (8/14) response rate, respectively.
Data collection and analysis
Round 1 generated training-related statements. Participants were invited to write as many statements as they would like regarding training considerations. The research team reviewed these statements for topic relevance and redundancy. In addition to ranking statements, participants were asked basic demographic questions. The demographic questions included the following information: assessing their role in MGEs, what countries their events occurred in, what type of working roles within MGEs they fulfilled, how many years they have participated in MGEs, and their health profession title.
The second round used a 7-point linear scale for experts to rank each generated statement. The ranking ranged from “1” being “not at all important” to “7” being “extremely important.” Stat59 anonymized all statements and rankings. Consensus statements proceeded to rank central tendency by assessing the mean. The statements reached a consensus if the response had a standard deviation (SD) of less than or equal to 1.0.Reference Imanipour, Ebadi and Monadi Ziarat19. The 7-point linear scale was chosen for its intuitive scoring nature. As noted by Franc et al., with greater than 5 experts, there was a <10% chance of false grading using the 7-point scale, the standard deviation, and mean to measure consensus.Reference Franc, Hung and Pirisi25
The third round excluded statements that met consensus from round 2. Again, statements were considered essential or prioritized if they obtained an SD less than or equal to 1. The remaining 52 statements proceeded to round 3, with 8 respondents participating. Of these, 40.3% reached consensus (21 out of 52). Forty-two of the initial 73 statements (57.5%) met the consensus standards by round 3. All statements that met consensus are noted in Table 1. See Appendix 1 for statements that did not meet consensus.
Consensus statements grouped (it is important to train medical staff in/to….)
Data are presented per mean (SD) for continuous variables
Consensus themes
Further data evaluation consisted of grouping consensus statements based on the mean. If the consensus statement had a mean of 6 or more significant, it was evaluated for a similar theme among the other statements. Several priority themes were identified. This included venue-specific information, good staff orientation to operations and capabilities, and community coordination. Table 2 shows 23.8% (10/42) of consensus statements centered around the venue-based theme. Mass casualty preparation and triage were secondarily highlighted as a critical focus, as noted in Table 3. As illustrated below, MCI and triage encompassed 14.2% (6/42) of the consensus statements. Less prominent themes included advanced life support skills, acute life-saving measures, and substance abuse issues.
Venue-specific issues (it is important to train…)
Data are presented per mean (SD) for continuous variables
Mass casualty and triage (it is important to train…)
Data are presented per mean (SD) for continuous variables
High impact priority statements
After final consensus analysis, the 10 highest-priority statements were identified based on their mean ranking scores, as shown in Table 4. These statements represented training areas with the strongest expert agreement and the least variability (SD ≤0.7 across all top 10 statements). Core competencies emphasized included AED use and placement, venue-specific orientation, mass casualty triage, environment-related emergencies (such as hyperthermia and hypothermia), airway management within their scope of practice, recognition of unstable patients, venue medical equipment familiarity, communication system use, and mass casualty management principles. These highest-ranked priorities reflect foundational skills deemed essential for safe and effective mass gathering medical response.
Top 10 statements (it is important to train medical staff in…)
Data are presented per mean (SD) for continuous variables
Results
Demographics
Fourteen experts specializing in Mass Gathering Medicine generated the initial statements. Professional titles included Medical Doctor (MD), Doctor of Osteopathy (DO), Doctor of Philosophy (PhD), combined MD/PhD, combined Registered Nurse (RN) and PhD, and Physician Assistant (PA). Twelve respondents had a mixture of employed and voluntary roles at MGE. Two were solely employed for MGEs. These experts identified their practice in the following geographic locations: the US (5), US and globally (1), Canada (1), Egypt (1), Switzerland and globally (1), Geneva and globally (1), Ireland (1), Belgium (1), and Indonesia (1). Years of experience ranged from 3-35 years, with a mean of 17.1 years. Self-described roles included an epidemiologist in public health for MGE, 10 MG Medical Directors, 1 on-site medical care provider, and 6 worked on MG research, in addition to their other duties. Seven participants were also active in training for MGE.
Round 1
Fourteen participants in the study’s first round generated 137 statements. The researchers manually standardized the statements to express only 1 observation in a similar pattern for each statement. They eliminated redundant statements and statements that did not clearly express subject matter related to MGE staff training goals. After standardization, 73 statements proceeded to round 2.
Round 2
Nine respondents participated in round 2. Based on the standard deviation, 28.7% of the statements (21/73) found consensus and dropped from advancement to round 3.
Round 3
The remaining 52 statements were analyzed in round 3, with 8 respondents participating. Of these, 40.3% reached consensus (21/52). Forty-two of the initial 73 statements (57.5%) met the consensus standards by round 3. All statements that met consensus are noted in Table 1. Supplementary File 1 contains statements that did not meet consensus.
Discussion
The primary contribution of this study is establishing core competencies for medical staff involved in MGE. Ensuring uniform baseline skills among event medical staff is poised to assume greater significance in the upcoming 5 decades. Currently, 10% of the global population includes individuals over 65. By 2060, this number is expected to double.26 The rising median age will likely increase the general risk of medical care needs at MGEs, even without intentional incidents.Reference Tavan, Tafti and Nekoie-Moghadam27 In parallel, the presence of children at many mass gathering events adds additional complexity to medical preparedness. Children are more vulnerable to medical insults than adults. Their physiologic differences and developmental stages can lead to rapid deterioration if not recognized promptly. Medical providers staffing MGEs may not routinely care for pediatric patients, creating potential delays in early identification, triage, and treatment.Reference Desmond, Schwengel and Chilson28 Though this study did not exhibit overwhelming support for special population training, the statement did meet consensus. It is worth further conversation to consider incorporating specialized training for these at-risk populations. The study findings offer a structured framework for training and preparing medical staff for MGEs, including venue-specific training and orientation, MCI, triage, and acute life-saving interventions. This study aimed to identify the core competencies of medical event staff and fortify preparedness and response capabilities amidst evolving demographic dynamics and emerging challenges.
The high-impact competencies identified by experts offer immediate, actionable targets for mass gathering medical training programs. Notably, several competencies, including AED deployment, venue-specific orientation, and mass casualty triage, achieved exceptionally high consensus, with mean scores exceeding 6.5. This strong agreement suggests that regardless of the diversity of MGEs, there are clear universal skills that all event medical staff should possess. Prioritizing these core areas could standardize baseline preparedness, enhance early response capabilities, and mitigate preventable morbidity and mortality during large-scale events. Importantly, many of these top priorities are straightforward to incorporate into short orientation sessions or pre-event briefings, supporting scalable, event-tailored training strategies.
Venue-specific knowledge ensures the medical staff is familiar with the layout, potential hazards, and on-site resources, enabling them to act more effectively during emergencies. Previous MGE studies have identified venue familiarity as critical for improved response to resuscitation events.Reference Ranse and Zeitz29 The importance is not surprising. As seen in other aspects of medicine, equipment and hospital system knowledge gaps contribute to poor patient outcomes.Reference Tucker and Edmondson30
It is not any different at an MGE. Most staff, if appropriately certified, have enough basic medical knowledge to treat most of the patient issues presented at MGEs.Reference Locoh-Donou, Guofen and Welcher31, Reference Varon, Fromm and Chanin32 However, there can be a significant delay due to a lack of familiarity with the venue or equipment.Reference Ranse and Zeitz29 MGEs usually require alterations in standard traffic flow. Staff well-versed in venue-specific egress plans are essential, particularly since EMS response times can be delayed due to roadblocks and rerouted traffic patterns.Reference Koski, Pappinen and Kouvonen33 Venue-specific training for MCI should be addressed for appropriate, preplanned collection points to help with EMS transport.
The research emphasizes operational knowledge, such as understanding emergency command structure (e.g., Incident Command System (ICS) or Major Incident Medical Management and Support (MIMMS)) and communication protocols within the event context. The study underscores the importance of MCI and triage training. This focus is particularly relevant given the unpredictable nature of large gatherings and the potential for high-casualty incidents. The emphasis on preparedness aligns with previous observations by Lund et al., who have noted parallels between MGM and Disaster Medicine (DM), underscoring the importance of comprehensive training and readiness initiatives in both domains.Reference Lund, Gutman and Turris34
Limitations
While this study provides a foundational step towards standardizing training for medical staff at mass gatherings, it has inherent limitations as it is an expert opinion piece. Additionally, the relatively small sample size, although within typical ranges for Delphi studies, might limit the generalizability of the results. As noted by Franc et al., Delphi studies with more than 10 respondents generate considerable accuracy.Reference Franc, Hung and Pirisi25 However, this study does fall within the standard range expectations of most Delphi studies, with 8-20 experts.Reference Shang35 The global experience noted by the respondents helps authenticate the current findings. Ogbeifun et al. noted that specific expert selection helps prevent herd mentality response.Reference Ogbeifun, Agwa-Ejon, Mbohwa and Pretorius36 The wide breadth of experience and specific choice of high-level experts in the field help validate the study response and conclusions. Future research should focus on enhancing external validity through randomized sampling methods and more diverse participant groups that can be widely implemented.
Conclusion
This study highlights expert opinion on the core competencies of the medical staff at MGEs. The high-priority, recurrent themes noted could serve as a basis for developing training competencies. Future aims are enhancing the preparedness and effectiveness of medical interventions at large-scale events by focusing on venue-specific operations, community coordination, and critical incident management. Medical event staff need certain training basics, given that the volunteer medical staff has varying degrees of knowledge. Establishing such competencies is a pivotal step towards professionalizing and standardizing the medical response at mass gatherings on a global scale.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/dmp.2025.10075.
IRB approval
BIDMC-Harvard IRB (Protocol #: 2023P000855) on 10/20/23.
Author contribution
All authors have contributed substantially to this work, including aspects of inception, manuscript writing/revision, and approval of the final manuscript as submitted.
Competing interests
JMF is the CEO and Founder of STAT59. All other authors declare that they have no conflicts of interest to disclose.
