Introduction
A mass gathering is defined as an event, planned or spontaneous, where the number of people attending is sufficient to strain the planning and response resources of the community, state, or nation in which it is hosted.Reference Hutton, Savage, Ranse, Finnell and Kub 1 Examples of mass gatherings include music festivals,Reference Hutton, Ranse, Verdonk, Ullah and Arbon 2 , Reference Lund and Turris 3 religious gatherings,Reference Arbon 4 and sporting events (such as football gamesReference Hutton, Savage, Ranse, Finnell and Kub 1 , Reference Forero, McCarthy and Hillman 5 and marathonsReference Doherty 6 , 7 ). Mass-participation sporting events, such as marathons, are increasingly common forms of mass gatherings.Reference Jena, Mann, Wedlund and Olenski 8 , 9 Mass gatherings often occur in well-established community spaces.Reference Hutton, Cusack and Zannettino 10 While they can provide a significant economic benefit to local communities,Reference Barnes and Henrickson 11 they can also impact upon existing community resources.Reference Saayman and Saayman 12
To date, mass-gathering research has predominantly focused on the nature of in-event health care provision at mass gatherings,Reference Hutton, Ranse, Verdonk, Ullah and Arbon 2 , Reference Arbon 4 , 9 , Reference Hutton, Roderick and Munt 13 – Reference Gannon, Derse, Bronkema and Primley 16 as well as the in-event incidence and severity of injuries.Reference Agar, Pickard and Bhangu 17 – Reference Videbæk, Bueno, Nielsen and Rasmussen 20 For sporting mass gatherings, anywhere between three percent and 18% of participants require health care,Reference Doherty 6 , Reference Agar, Pickard and Bhangu 17 , Reference Tang, Kraus, Brill, Shahan, Ness and Scheulen 21 often delivered on-site. With increasing popularity of running events and evidence of increasingly inexperienced runners participating in endurance events, effective injury management for many patients is important.Reference Jaworski 22 These injuries are mostly mild musculoskeletal and soft tissue injuries with only a few severe enough to warrant transport to hospital.Reference Jaworski 22 , Reference Fredericson and Misra 23
For planning purposes, it is important to understand the impact on and requirements for local acute health services, including surrounding emergency departments (EDs)Reference Hutton, Cusack and Zannettino 10 , Reference Tang, Kraus, Brill, Shahan, Ness and Scheulen 21 during mass gatherings; however, research in these areas is limited. Calls for “development of evidence-based guidelines for medical and disaster preparedness of marathon races”Reference Glick, Rixe, Spurkeland, Brady, Silvis and Olympia 24 remain largely unanswered. Further research is also required to understand the most efficient and optimal method(s) of health care delivery during such events. The aim of this study was to describe clinical staff perspectives of the structures and processes required for an in-event health care service operating during the Gold Coast Marathon (Queensland, Australia).
Methods
Study Design
The structure and process components of Donabedian’s evaluation framework,Reference Donabedian 25 including the adaptations by Irvine, et al,Reference Irvine, Sidani and Hall 26 was used to guide this qualitative, semi-structured, interview-based study.Reference Baxter and Jack 27 Within these evaluation frameworks, structural components typically consider the resources required to operate the service/model of care (such as staff experience levels and knowledge), and organizational elements, including staffing (patient ratio/skill mix), physical, and social factors.Reference Irvine, Sidani and Hall 26 Process components include the professional roles and independent/inter-dependent relationships that are required to ensure the service can operate.Reference Irvine, Sidani and Hall 26 The pragmatic, interpretative approach adopted by the research analysis team positions the researchers within the context and enables collection of participant-generated meanings that focus on a single, locally constructed, and meaningful phenomenon;Reference Baxter and Jack 27 namely, the structures and processes of the in-event, acute health care service.
Participants
Participants were purposively selected and invited to participate in a semi-structured interview if they met the inclusion criteria: they worked during the 2016 Gold Coast Marathon weekend, at either the in-event, acute health care service or in the main hospital ED. A range of clinical staff working in each location was invited. Twelve participants met the criteria and agreed to participate.
Study Setting
The Gold Coast Marathon 7 is one of several mass-gathering sporting events held in Australia. Since its inception in 1979, the number of participants has increased from approximately 1,000 to over 43,000 in 2017. 7 An in-event health care model has been developed and operated predominantly by local public hospital ED staff to help meet the health care needs of this unique, transient population.
For this study, the settings included the in-event health care facility and the ED. The in-event health care facility was operational for two successive mornings of the sporting mass gathering. The 750-bed, public, tertiary, teaching hospital ED (which provided staff to work in the in-event health care facility) was located approximately five kilometers from the in-event health care facility and managed 104,000 annual ED presentations for the year 2015-2016. 28
Morning one of the marathon events includes a 2km (children’s) sprint event, as well as 5km and 10km events. 7 Morning two includes the half-marathon (21km) and full-marathon (42km) events. All events take place on local roads closed to vehicle access. The track has a total ascent of 167.2 meters and a maximum elevation of 20.6 meters. Temperatures fluctuate with average July temperatures ranging from 9oC-20oC (48oF-68oF). Thus, it is considered a fast, flat track. 29
Data Collection
Data were collected via semi-structured interviews that lasted between 16-54 minutes. These were undertaken by two experienced researchers (AJ and JW) from August through October 2016. Interviews took place in a private room within the ED at a time convenient for the participant. One participant was interviewed by phone. Each interview was audio recorded and then transcribed verbatim for analysis. Interview questions were informed by the Donabedian framework,Reference Donabedian 25 and by specific clinical components highlighted by Irvine, et alReference Irvine, Sidani and Hall 26 focusing on describing the structures and processes required to operate the marathon health tent. Examples of questions asked of participants included: “What do you need to do your job at marathon health tent?” “Can you tell me about your role in delivering healthcare in the marathon health tent?” and “How do you decide if someone needs to be transferred to ED for definitive emergency care?” On-going clarification of meaning and intent was undertaken during the interview.Reference Elo and Kyngäs 30 Interviews enabled researchers to capture detailed and rich descriptions of participants’ personal experiences.Reference Baxter and Jack 27 , Reference Petty, Thomson and Stew 31 Some simple demographics were also recorded from participants (Table 1).
Demographic Characteristics and Clinical Experience of Interview Participants
Abbreviation: ED, emergency department.
a Senior nurse was defined as a nurse holding a clinical nurse (senior grade) paid position, rather than a given range of ED experience.
Data Analysis
Two researchers (AJ and JW) independently reviewed the transcribed interviews for accuracy prior to independent content analysis. Analysis involved coding the data, using a priori codes, and linking it to the research questions describing the in-event, acute health care facility health tent structures and processes, based on Donabedian’s framework.Reference Donabedian 25 , Reference Bogdon and Biklen 32 These codes were “structures” and “processes.” Structures, within the Donabedian framework, describe the characteristics of the setting in which the health care was provided, including material resources such as equipment, location, and money/costs.Reference Donabedian 25 Structures also include the human and organizational resources required to meet organization outcomes, such as patient flow, and thus, these (material resources, human resources, and organizational resources) became the sub-codes. Processes are the processes undertaken to ensure care delivery in the in-event health care setting, and were considered in terms of independent, directed, and inter-dependent care processes by clinicians.
Sequential, deductive, and then inductive analyses of the text data were undertaken to produce a description that has capacity for transferability to other settings.Reference Elo and Kyngäs 30 The inductive analysis involved reading and re-reading the data within each a priori category (Table 2 and Table 3) to develop codes that could condense extensive and varied raw text data into a brief summary format, while also establishing clear links between the research objectives and the summary findings derived from the raw data. Deductive reasoning sought to synthesize the emerging data from the particular to the general to help support broader understanding for each analysis category.Reference Elo and Kyngäs 30 The process was iterative, with researchers reviewing the data and codes, and revising coding as new insights emerged.Reference Bogdon and Biklen 32 For example, as an understanding of the staffing in the in-event health service emerged, researchers were better able to interpret clinical assignment patterns (task allocation/acceptance).Reference Irvine, Sidani and Hall 26 Discussion of coding with other researchers was undertaken regularly.
Structures of the Gold Coast Airport Marathon In-Event Health Care Service
Note: “Structures” describe the characteristics of the staff and setting in which the health care was provided that might affect clinicians’ capacity to engage in their role functions.Reference Donabedian 25 , Reference Irvine, Sidani and Hall 26
Abbreviations: ECG, electrocardiogram; EDIS, emergency department information system; IV, intravenous; QAS, Queensland Ambulance Service; RN, registered nurse.
Processes Contributing to the Gold Coast Airport Marathon In-Event Health Care Service
Note: Processes describe the role functions and responsibilities of the staff in which the health care was provided.Reference Donabedian 25 , Reference Irvine, Sidani and Hall 26
Abbreviations: ED, emergency department; QAS, Queensland Ambulance Service.
Rigor
Analysis of data collected used a parallel perspective, as described by Lincoln and Guba.Reference Lincoln and Guba 33 A number of measures (transferability, credibility, dependability, and confirmability) were used to enhance the rigor of this study, including purposeful sampling.Reference Elo and Kyngäs 30 Data analysis included the construction of an audit trail and collection of thick, rich descriptions of participants’ experiences, enabling identification of recurrent patterning to enhance dependability and trustworthiness.Reference Tracy 34 Researchers spent time in the in-event, acute health facility and the ED to contextualize interview content, and thus, application of a self-reflexive stance that was critical and informative to enrich the dependability and credibility of data coding.Reference Campbell, Quincy, Osserman and Pedersen 35 Rigor was increased further through the independent coding and interpretation of the raw transcript data; interviews were re-coded by another researcher to check for reproducibility of emergent codes,Reference Popping 36 which were finalized via consensus decision.Reference Campbell, Quincy, Osserman and Pedersen 35 Finally, contextual details covering the setting, structures, and processes are provided, as well as direct quotes from the interviewees, so that readers can undertake their own evaluation of the generalizability of the findings.Reference Elo and Kyngäs 30 , Reference Popping 36
Ethics
Human research ethics committee approval was obtained from Gold Coast Hospital and Health Service (HREC/16/QGC/37; Queensland, Australia) and Griffith University (GU Ref No: 2016/206; Queensland, Australia).
Findings
Demographics
Demographic and clinical characteristics of the 12 interview participants are summarized in Table 1. Participants were key stakeholders including eight nurses and four doctors with a range of clinical experience.
Context
In-event health care facilities were provided to marathon staff, volunteers, bystanders, and participants within the protected boundary of the event, inclusive of the final two kilometers of track, an area with otherwise limited ambulance access and egress. Injured or ailing athletes self-presented or were assisted to the facility by first aiders, friends, volunteers, or paramedics. Treatments provided to marathon participants ranged from minor conditions (such as a dressing for blisters and abrasions) to potentially life-threatening conditions (such as myocardial infarction). Other health care provision for the event included the Queensland Ambulance Service (QAS; Queensland, Australia) and volunteer services (State Emergency Service [Queensland, Australia] and St John Ambulance Australia [Queensland, Australia]). The QAS provided paramedical assessment, management, and transport to health care facilities for event participants or spectators that typically occurred far from the in-event health care service. Volunteer first aid services provided simple, first point-of-care, primarily to spectators. The in-event health care service was co-funded between the local health service and event organizers.
Structures
Structures underpinning the in-event health care facility included human resources and organizational structures. These are presented in Table 2, along with exemplar quotes from interview participants reflecting these structures.
Human Resources
Medical and Nursing
The health service contributed human resources such as medical, nursing, and administrative staff, drawn primarily from the health service EDs, but also including ward and clinical staff from the intensive care unit. Staff were invited to work in the in-event facility via an email that requested submission of expressions of interest, and by word of mouth/prior knowledge. The number of staffs recruited was titrated based on previous and expected ED and in-event demand, the number of race registrations, and environmental conditions. Generally, six to eight nurses, three to four doctors, and one to three administrative staff worked in the in-event facility each day. Staffing varied throughout the day, based on anticipated and actual need. When staff were required at the main EDs, they could be drawn directly from the on-site health care tent team.
Interview data revealed that no specific nursing or medical skill sets were required, although few, if any, inexperienced staff were selected unless they had a personal interest in sports medicine and care. Staffing allowed for capacity building where those with limited or no in-event experience were offered the opportunity to work in the setting along slide other experienced staff (capacity building). It also ensured adequate staffing at the main EDs. Interview participants consistently stated the need for fair and demand-dependent human resource sharing between the hospital EDs and the in-event heath care service.
Other Human Resources Support
Participants reported that the Gold Coast Marathon organizers reportedly provided daytime and overnight security so that equipment could be left on-site overnight. Gold Coast Marathon organizers also coordinated trained volunteers to assist physical patient retrieval from the track.
Organizational Structures
Organizational structures of the in-event health care model were considered in terms of physical and social organizational structures. With regards to the physical organizational structures, these included equipment (material resources), facilities, location, funding, and resource documents.
Physical Organizational Structures
Material Resources
The health service contributed material resources, including equipment such as assessment devices, thermometers, sphygmomanometers, 12-lead electrocardiograms (ECGs), and medications such as intravenous (IV) fluids. They also contributed other consumable health care resources, such as bandages and icepacks, while event organizers contributed physical space and basic physical setup (ie, tent, eight plastic patient chairs, and 12 stretcher/tables). The event organizers resources included shortwave radios for in-event communication, including with QAS and first aid providers. Staff provided their own mobile phones for communication with the main hospitals. Electronic devices, such as iPad scanners (Apple; Cupertino, California USA) to register participants attending the event and track participants, supported effective communication.
Facilities, Location, Funding, and Supporting Documentation
Organizational structures were provided to meet both anticipated patient service demand and anticipated care requirements for the event-induced physiological complaints (based on previous experiences). The in-event marathon health care facility (marathon health tent) was a 10mx22m tent with on-site power (as described in the quotes in Table 2). The facilities internal design was structured to enhance patient flow, with clearly delineated areas for patient registration, treatment of minor injuries (chairs at the entry/triage point), and stretchers around the tent internal circumference to care for additional patients. Eight patient chairs were clustered around the entry/triage point and 12 stretchers were zoned into the four quarters of the tent. Central tables housed assessment and treatment equipment to allow ease of access.
Medical and administrative equipment was driven to the site from the local EDs and was often part of the recycling/updating/reviewing of the health services’ disaster response equipment and consumables. The organizational equipment provided was sufficient to enable provision of a wide range of on-site clinical care, from minor injuries to high-acuity resuscitation care. Equipment was required to enable a range of clinical assessments such as vital signs (blood pressure, temperature, blood-oxygen saturation, and blood sugar levels) and ECGs.
Organizational structures, including lists of material and staff resourcing, were set out in a briefing document provided to clinical and administrative staff approximately two weeks prior to the event. This briefing document described the in-event resources available, the in-event tent location, access and egress points, and patient flow processes. Organizational structures were also outlined to in-event health care facility staff via verbal orientation at the start of each shift.
Social Organizational Structures
Clinical, patient transport, and administrative roles were described in many ways, with apparently overlapping and shared responsibilities for transportation, patient care, and administrative components of care delivery. There was a clear role for senior staff, particularly doctors, to initiate and maintain communication, predominantly with the hospital EDs. An in-event nursing leader originally set in place (in consultation with two lead medical consultants), and then described the organizational social structures. These organizational social structures were explained to staff at the start of each shift. Clinical seniority was de-emphasized, but clear routes of communication and resource sharing were reinforced.
While most clinical staff interviewed were typically aware of material and human resourcing, they rarely commented on organizational resources such as funding models or locational constraints. Staff generally commented very positively on the flexibility in organizational social structures, indicating that this made the work more informal and fun, as well as enabling some staff to be clinically challenged.
Processes
Processes of in-event health care included the processes around selecting clinical staff, clinician’s treatment of recipients, patient flow through the facility (ingress, allocation, assessment, treatment, discharge, or transfer), and communications around and supporting all these processes. Staffing selection processes included circulation of a staff email, requests for staff nominations, and then a process of team development. Staff allocated to the in-event facility were balanced off the need for experienced clinicians in the main EDs and against the need for experiential development of staff and succession planning for organization and operation of in-event health care delivery. The processes of staff selection considered the relative needs and demands of in-event health care delivery compared to the demands for provision of health care by hospital emergency staff in the main EDs. Consideration of the equity of these processes was highlighted by senior staff (Table 3). Once staff were selected and approved, staff were provided with a short, pre-service briefing and an on-site orientation.
Clinical processes were considered in terms of independent, directed, and inter-dependent care and are set out in Table 3, together with exemplar comments from interview participants. While clinical scope for doctors and nurses did not change based on whether they were working in the main EDs or the in-event health care facility, there was limited clinician-specific independent care. During an average shift in the in-event health care facility, nurses and doctors undertook many similar clinical processes for patients, including triaging, allocation to specific regions in the tent, initial assessments, administration of simple treatments (ice, oral fluids, or sugar supplements), and the provision of discharge information. This was noted as a departure from usual practice in which there was often distinct role separation; for example, in EDs, triaging is typically seen to be a nursing responsibility, while provision of discharge information might be recognized as medical responsibility. Some roles were distinct to specific clinical entities. For example, care escalation to the main EDs was primarily coordinated by medical staff, while liaison between other health staff (QAS and first aid) and staff in the in-event health care facility was undertaken primarily by the senior nurse.
Inter-dependent care between the in-event clinical staff and other health care providers was also evident. For example, a doctor stationed at the event finish line (supported by first aid and clinical staff) would provide preliminary triage in collaboration with first aid and nursing staff. Referral to the in-event health care facility was undertaken by both nurses and doctors, often working in concert. Around the course, QAS and/or first aid staff were stationed at various locations to provide initial care and transport to the in-event health care facility or the hospital ED. Patient acuity, rather than location, was the primary driver for transport destination.
All interviewees reported that the model was operational because of multi-disciplinary and inter-agency collaboration between QAS, St John’s Ambulance, nurses and doctors, and event staff. Interviewees also clearly enunciated clinical goals set around reducing patient transport to the hospital EDs, managing patients wherever possible on-site, and providing a valued community service.
Interviewees reported that they could provide the kinds and levels of patient care they expected in this context, ensuring immediate patient comfort and safety. Despite the apparent satisfaction with relative clinical independence, both groups of clinical staff described a shared team approach to care provision in which positively engaged clinicians supported and enhanced care delivery.
Communication
Communication in the marathon health tent was relatively informal. The small size of the in-event health care facility, the short distances (meters) across which staff needed to communicate, and the open casual setting in the marathon health tent enabled direct person-to-person, multi-disciplinary, professional and informal (social) communication.
A clearly defined process for communication, established by the senior doctors working at the in-event, acute health care facility, involved pre-defined lines of consultation between staff working within the in-event health care facility and staff located around the course and in hospital EDs. This contact exclusively utilized mobile phones direct to clinical contact numbers in the EDs (consultant direct to ED consultant or ED shift coordinator). The nursing cohort recognized these “medical” communication processes, but viewed their own communication styles as more casual, especially when compared to their normal role within the ED, and primarily focused within the in-event health care facility.
Communication between the in-event health care facility and the QAS and on-site first responders was via radio contact. If a patient was to be transferred to the main ED directly via QAS, the usual communication protocols were observed. If the patient attended the in-event, acute health care facility and was then to be transferred, the senior medical consultant in the in-event, acute health care facility phoned the medical team leader at the ED to provide direct notification and an initial handover. The formal (written) records pertaining to the patient were provided primarily by transporting QAS paramedics with addendums from nursing and medical staff in the in-event, acute health care facility.
Occasional communication or organizational failures between the triage staff at the main EDs and ambulance or in-event, acute health care facility staff resulted in hospital ED triage nursing staff reporting that they sometimes felt unable to prepare for anticipated increased presentations (Table 3). Staff working at the local EDs identified less well-defined or consistent policies and protocols for communication across health care sites, set within a context of increased preload and patient demand on the ED, created by the Gold Coast Marathon event in addition to normal expected ambulance patient load.
Perceived Benefits and Opportunities of In-Event Health Care Delivery
In addition to structure/process elements identified, staff managing patient flow at the ED and staff in coordinating roles at the in-event health care facility reported that hospital avoidance was an important consideration of the in-event, acute health care facility. The in-event health care facility was identified by staff at both sites (in-event and main EDs) as a positive contribution to patient flow in the main EDs and to the broader community. In-event staff also perceived participating in health care delivery at the marathon tent as having positive social aspects, providing an opportunity to encourage/enhance positive community perceptions about the local EDs. They also valued it as an alternative working experience. Examples of such comments are included in Table 3.
Opportunities for Service Improvement
Very few opportunities for service improvement were reported by staff. Some staff indicated that inter-service (QAS/other clinical staff) communication could be strengthened to ensure that all prehospital staff were equally aware of the medical scope available in the in-event facility. They also highlighted additional/improved equipment (such as mobile radiology and ultrasound scans) that might assist care delivery. Such equipment could enable in-event staff to provide more in-event assessment, and thus, a greater capacity for either directly discharging patients or a more complete handover on transport to the main EDs. Equipment location (finding things on the long, central equipment benches) was sometimes challenging, but generally staff perception was that the care model worked well. Some concerns around the funding model used (mostly regarding lack of understanding) were raised by senior staff, primarily around the costs to the local health care service budget.
Discussion
The number of mass-gathering sporting events continues to grow both within Australia and internationally.Reference Nguyen, Milsten and Cushman 19 , 37 This growth requires careful consideration as to how best provide health care to support athletes and onlookers, while minimizing the impacts on local EDs and the community. The Gold Coast Marathon was a sporting mass gathering where the delivery of in-event health care provided an opportunity to describe the structures and processes of this model. Broadly speaking, staff operating from the in-event facility and the main EDs reported positively on the structures and the processes in operation.
While many events, sporting and other, offer in-event health care, few offer such a breadth of both clinically experienced and senior staff operating within a wide scope of intervention. Many in-event health care services are operated by volunteers,Reference Hutton, Ranse, Verdonk, Ullah and Arbon 2 , Reference Lund and Turris 3 , Reference Doherty 6 , Reference Khorram-Manesh, Berner, Hedelin and Ortenwall 14 despite calls for evidence-based guidelines and published data to support medical planning for marathon races.Reference Tang, Kraus, Brill, Shahan, Ness and Scheulen 21 , Reference Glick, Rixe, Spurkeland, Brady, Silvis and Olympia 24 , Reference Schwellnus and Derman 38 , Reference Zeitz, Zeitz and Arbon 39 Indeed, current evidence suggests that workforce planning for mass gatherings is often a very inexact science.Reference Woodall, Watt and Walker 40 It is not unusual for mass gatherings to provide on-site medical, as well as nursing and first aid, clinical support.Reference Gannon, Derse, Bronkema and Primley 16 , Reference Agar, Pickard and Bhangu 17 , Reference Nguyen, Milsten and Cushman 19 , Reference Burton, Corry, Lewis and Priestman 41 , Reference Grange, Baumann and Vaezazizi 42 The provision of such support can reportedly result in high-quality, timely care, effectively screening patients in-event and reduced transfers to, and thus demands on, local EDs. 9 , Reference Nguyen, Milsten and Cushman 19 , Reference Tang, Kraus, Brill, Shahan, Ness and Scheulen 21 , Reference Zeitz, Zeitz, Arbon, Cheney, Johnston and Hennekam 43 Despite models of in-event patient presentation and transportation rates for a range of mass-gathering events,Reference Zeitz, Zeitz and Arbon 39 , Reference Arbon, Bridgewater and Smith 44 , Reference Turris, Lund and Hutton 45 and evidence of impacts of mass gatherings on health service care provision,Reference Jena, Mann, Wedlund and Olenski 8 , Reference Tang, Kraus, Brill, Shahan, Ness and Scheulen 21 , Reference Ranse, Hutton and Keene 46 there are relatively few systematic and detailed descriptions of delivery of in-event care.
The data collected in this study suggested that medical and nursing staff perceive they have a good understanding of the resources available and the limitations of in-event health care provision, acknowledging in their responses that most of their health care delivery was affiliated with minor and event-induced physiological complaints. Clinicians indicated that the resources available to perform their roles were well-aligned with the health care needs of patients. In its primary capacity, the in-event, acute health care facility was apparently resourced to deliver health care to varied minor injuries and event-specific induced physiological complaints. Staff, however, expressed satisfaction with the in-event resources which were sufficient to enable them to expand functions so as to operate as a single event prehospital resuscitation space, if a situation arose that required levels of intensive/emergency care. This appeared to have evolved from staff experience, rather than from published evidence.
The equipment and environment enabled delivery of an effective health service within an efficient operational patient flow system. Well-defined routes of clinical communication assisted with service delivery, and the importance of inter-service communication was clear. The marathon health tent service has the added advantage of provision of facilities and even rehearsal/equipment check for mass-casualty events, ensuring that staff were familiar with the content and layout of the basic disaster response equipment. Indeed, the clinical aegis under which the facility is operationalized is the disaster response and management banner.
The in-event health care facility offered incidental benefits to staff. These included reports of improved ease of communication, perceptions of enhanced team work, staff satisfaction, and opportunities to test the use of their skills in an out-of-hospital setting. Staff reported satisfaction with the notion of offering a valuable community service.
Limitations
Limitations identified using this research design and enquiry process include, as with most qualitative work, the use of non-random sampling strategies of purposeful and snowball sampling with the accompanying risks of small sampling bias. However, the sampling strategy used is considered a stronger option than availability or convenience sampling,Reference Daniel 47 and data saturation was achieved within data collected from two groups of clinicians.Reference Elo and Kyngäs 30 The study was undertaken at one site, focusing on one type of mass gathering (sport), limiting the transferability of findings to other sites or types of mass-gathering events. Additionally, this study evaluated a care provision model staffed primarily by ED nurses and doctors. Other models of care staffed with a different skill set may have different findings.
Conclusion
Findings from this study highlight key structures of the in-event health care facility included equipment, security, space and skill-mix, and processes such as communication and referral pathways. These were important components for the delivery of emergency care in the out-of-hospital setting. There was a perception of shared and united treatment goals by clinical staff, and a team approach to meet process aims. Recommendations for future research include considering the health patients’ experiences of services provided.
