American Journal of Emergency Medicine (2009) 27, 337–343

www.elsevier.com/locate/ajem

Brief Report

Predicting resource use at mass gatherings using a

simplified stratification scoring model
Nicholas Hartman BA a, Allen Williamson RN b, Benjamin Sojka BA, EMT-P c,
Kostas Alibertis EMT-P c, Marjorie Sidebottom BA d, Thomas Berry MHA e,
Jay Hamm RN, MPH b, Robert E. O'Connor MD a,b, William J. Brady MD a,b,c,⁎
a
Department of Emergency Medicine, University of Virginia, Charlottesville, VA 22908, USA
b
Special Event Medical Management, University of Virginia Health System, Charlottesville, VA 22908, USA
c
Charlottesville-Albemarle Rescue Squad, Charlottesville, VA 22901, USA
d
Office of Emergency Management, University of Virginia, Charlottesville, VA 22908, USA
e
Emergency Preparedness, University of Virginia Health System, Charlottesville, VA 22908, USA

Received 14 March 2008; revised 29 March 2008; accepted 31 March 2008

Abstract
Introduction: Mass gathering events require varying types and amounts of medical resources to deal
with patient presentations. The needs of various events have so far been difficult to predict with
precision, yet likely are impacted by several factors which may be used in a predictive fashion.
Hypothesis: Medical needs at mass gathering events can be predicted based on a combination of
weather, number in attendance, presence of alcohol, demographic of the participants in attendance, and
crowd intentions. Furthermore, each of these factors can be assigned a score and events can be stratified
based on that score.
Methods: Fifty-five mass gathering events of varying type occurring in proximity to a large mid-
Atlantic university were analyzed retrospectively. Based on a scoring system using the factors described,
the events were categorized as “minor,” “intermediate,” or “major.” The actual medical needs at each
event were then analyzed.
Results: Twelve events were classified a priori as “minor,” 20 events were classified as “intermediate,”
and 23 received a classification of “major.” These events had averages of 2.3, 6.3, and 71 total contacts,
respectively. These trends were consistent for minor encounters, major encounters, and transports. The
classification system correctly predicted the resource demand for the 3 classes of events.
Conclusion: A classification system that stratifies events based on weather, number in attendance,
presence of alcohol, demographic in attendance, and crowd intentions can effectively predict medical
needs at mass gatherings. This system is most accurate in the description of minor- and intermediate-
type events; major events were less well described by this classification system.
© 2009 Elsevier Inc. All rights reserved.

1. Introduction

⁎ Corresponding author. Department of Emergency Medicine, Uni- Public mass gatherings present a unique challenge for
versity of Virginia, Charlottesville, VA 22908, USA. those who plan for emergency medical services (EMS).
E-mail address: wb4z@virginia.edu (W.J. Brady). Various groups, including the National Association of EMS

0735-6757/$ – see front matter © 2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.ajem.2008.03.042
338
physicians, have defined mass gatherings as “any event in
which 1000 persons are gathered at a specific location for a
defined period of time” [1]. These events carry the potential
to consume medical resources, ranging from few to many,
depending on a number of factors. These gatherings take
place in a variety of settings with varying circumstances that
could affect the type and quantity of medical emergencies.
Several attempts have been made to identify and quantify
these determining factors. Developing a method using these
variables which could guide event planners in the expected
patient care needs would be of significant value.
Most studies in the field of mass gathering medicine have
been descriptive, and only a few have attempted to analyze a
variety of events and predict patient volume based on
causative factors. Events ranging from agricultural shows to
the International Olympics have been described and have
been instructive [2]. The literature in this field, though, is
moving increasingly toward discovering methods which can
prospectively predict medical resource use [3]. Two of the
proposed models are worthy of consideration in that they
represent 2 basic event planning approaches. The Zeitz Model
[4], one point of view, notes that the volume of medical work
can best be determined by examining historical data for a
specific event and forecasting on that basis. When these data
are available, for example with an annual event, this approach
seems prudent. Conversely, the Arbon method [5] uses a
statistical model, taking into account important factors such
as weather, event boundaries, and crowd mobility to estimate
medical needs. This particular model is designed for use at
gatherings with greater than 25 000 people. Both of these
approaches have validity and can be used.
If historical data are not readily available, or are not
reliable, it may be useful for planners to be able to categorize
events based on proven variables affecting patient volume. A
comprehensive review of mass gathering literature by
Milsten et al [6] concluded that medical needs were largely
determined by the following factors: event type and duration,
attendance, weather, crowd mood and density, weather, and
alcohol and drug use. This review took into account any type
of gathering that had been reported in the literature, ranging
from papal visits to popular musical concerts and National
Association for Stock Car Auto Racing races; other models
and descriptions have performed in similar fashion [7,8].
Any model that attempts to cover a wide range of gatherings
should include many of these variables.
The amount and type of medical resources devoted to each
mass gathering event should hinge largely on the forecast of
medical need. Medical personnel needed could range from
basic life support–trained emergency medical technicians to
physicians based upon medical utility and the type of
emergencies that can be expected. Precise estimates for
medical needs may or may not be needed, but it would be
useful to at least stratify events based upon projected patient
volume. Studies have shown that, although patient volume
may be high for some events, serious illness remains
relatively unusual at most gatherings [9]. Although this
N. Hartman et al.
may be true, the nature of these events often makes it essential
that proper resources be available if a disaster should occur.
Thus, it is essential to predict medical needs in a reasonably
accurate manner so that resources can be efficiently allocated.
This study is an attempt to classify mass gathering events
based on already established variables that influence the
number and type of medical needs. These factors include
weather, number in attendance, presence of alcohol, demo-
graphic of the participants in attendance, and crowd
intentions. With these variables, it is hypothesized that events
can be categorized as “major,” “intermediate,” or “minor,”
based on the likelihood of emergency medical needs, and
resources can be accordingly allocated. Weather, in this case,
will be represented by the heat index, a quantifiable factor that
has been previously shown to influence patient volume in our
system [10]. Attendance will be categorized in ranges, and the
presence of alcohol will be reported as either “significant,”
“limited,” or “none.” Demographic in attendance will be
concerned primarily with the age mixture, and crowd
intentions will be assessed according to the event type and
any historical data that might be available about the event.
The data for this study were derived from the experience
of the special events team at a large mid-Atlantic university.
The special events team, which is a partnership between local
EMS and the university ED, provides medical staffing for
mass gatherings at the university and in the surrounding area.
2. Methods
Records for 55 events were examined. These events were
chosen to provide a variety of sizes and circumstances under
which gatherings were held. They were also representative of
events for which the special events team provided staffing.
Only events for which appropriate records could be obtained
were included. Each event was analyzed based on expected
weather, attendance, presence of alcohol, age demographic,
and crowd intentions. In each category, individual events
were given a score of 0 to 2, with “0” corresponding to
minimal impact, “2” for significant impact, and “1” being
intermediate in impact. Events with a score greater than “5,”
or with scores of “2” in 2 categories, were classified as
“major.” Those events with scores greater than “3” but less
than or equal to “5,” or with a score of “2” in any one
category, were classified as “intermediate.” Gatherings with
scores less than or equal to “3” were labeled “minor.” The
scoring scheme is illustrated in Chart 1. Each of these events
was then examined to determine how many total patient
contacts occurred, and how many of these were of the full or
limited variety. Full contacts required full evaluations which
were defined as a full patient assessment by an advanced life
support EMS provider, nurse, or physician; these contacts are
referred to as full evaluations. Minor contacts, termed limited
evaluations, were defined as those that consisted of minimal
interventions such as basic wound care. In addition, note was
Predicting resource use at mass gatherings using a simplified stratification scoring model 339

Chart 1 Scoring system using weather, number of participants, presence of ethanol at the event, general crowd age, and crowd intentions
Weather (heat index) Attendance Ethanol Crowd Age Crowd intention Point value
N90°F (heat index) N15 000 Significant Older Animated 2
b90°F (heat index) climate not controlled 1000-15 000 Limited Mixed Intermediate 1
Climate controlled b1000 None Younger Calm 0
Major events: total score greater than 5, or scores of 2 in 2 different categories.
Intermediate events: total score greater than 3 but less than 5, or a score of 2 in any 1 category.
Minor Events: total score less than 3.

made of the number of EMS patient transports to the
university hospital ED.
3. Results
Twelve events were classified as minor, based upon the
classification system. Included in this group were high
school graduation, small concerts, and social engagements.
These events averaged 2.3 total contacts, with a range of 0 to
7. Limited evaluations, or those that did not involve a full
evaluation, averaged 1.8, with a range of 0 to 7 in this group.
Full evaluations, those that did involve a medical evaluation,
accounted for an average of 0.2 contacts, with a range of 0 to
1. An average of 0.1 transports took place at these events,
with a range of 0 to 1. Refer to Table 1 for a description of the
various events with a depiction of the full and limited
evaluations, EMS transports, and total contacts.

Table 1 Minor events

340
Twenty gatherings were classified as intermediate by the
scoring system. These events included basketball games and
concerts held at an indoor, climate-controlled arena with a
capacity of 15 000 persons. The average number of total
contacts in this group was 6.3, with a range of 1 to 21.
Limited evaluations averaged 3.9, with a range of 0 to 9,
whereas full evaluations averaged 0.9, with a range of 0 to 5.
Emergency medical service transports averaged 0.4, with a
range of 0 to 4. Refer to Table 2 for a description of the
various events with a depiction of the full and limited
evaluations, EMS transports, and total contacts.
Twenty-three events were categorized as major according
to the classification system. These events included 17 college
football games hosted at the university, with an average
attendance of approximately 60 000 persons. Also included
were 3 equestrian events (steeple chase racing) in the
surrounding area with an average attendance of 26 000, and 3
university graduation days for the university, for which
average attendance is estimated at 30 000 persons. This event
group saw an average of 71 total contacts with a range of 24
to 127. There was an average of 58.9 limited evaluations
Table 2 Intermediate events
N. Hartman et al.
with a range of 14 to 119, and an average of 14.3 full
evaluations, with a range of 4 to 57. Total EMS transports
averaged 5.5, with a range of 1 to 17. Refer to Table 3 for a
description of the various events with a depiction of the full
and limited evaluations, EMS transports, and total contacts.
Table 4 compares the summary medical needs of the 3
event types.
4. Discussion
Mass gatherings, defined as planned public gatherings
attended by more than 1000 persons [1], present a unique
challenge to public safety event planners in that the number
and severity of medical encounters are difficult to predict. In
fact, a great variability exists in both the number and type of
medical presentations [11,12]. Policy and operative proce-
dures used by emergency medical planners at these
gatherings have been based largely on case reports,
precedent, and the occasional local government regulation.
Predicting resource use at mass gatherings using a simplified stratification scoring model
Table 3 Major events
Highlighting the markedly variable nature of mass
gathering events and their related medical needs, patient
presentation rates (expressed as patients presenting per 1000
participants) have ranged from 0.14 to 90.0 patients per 1000
participants [13]. The prediction of medical need at a large
event is a difficult task. Many authorities note that numerous
factors, and their interrelationship, can assist in this difficult
predictive task. In fact, environmental factors, event type,
and crowd size have been suggested to correlate with patient
presentation rates [13].
Predicting the medical needs of a large group translates
directly into the similar prediction of appropriate medical
staffing for an event. Opinions vary considerably from those
that maintain on-site facilities are not required at all events,
to those that advocate the involvement of on-site physicians
to maximize patient care. Although the role of EMS
personnel as basic first aid, advanced life support, and
transportation providers has been well established, the
number of personnel has been largely based on past
341
experience with a specific event rather than on the
application of a predictive model [5,14].
The results of this study support the observation that
medical needs at mass gatherings can be predicted based on
the factors used in our model. The mean number of patient
encounters followed the classification system in order, as did
the range of patient encounters seen in each group. The
classification system was particularly effective in predicting
total number of patient contacts, especially in the minor- and
major event–type groups. The intermediate group demon-
strated more variability.
The scarcity of full evaluation contacts at minor events
suggests that only basic life support staffing is necessary.
Similarly, full evaluations at intermediate events were sparse,
although a few events did present a number of situations
requiring full evaluation and transport to the hospital.
Advanced life support personnel would seem prudent for
all the major events, where large numbers of patients
required evaluation and many transports were possible.
342
Table 4 A comparison of event type with patient presentations
(limited evaluations, full evaluations, EMS transports, and total
contacts)
Major events also required increases in the number of basic
life support personnel, as there was a parallel increase in both
limited and full evaluation contacts. Although the minor and
intermediate events did not demonstrate significant medical
challenge, the major event types represented considerable
need of medical resource. The variation in the magnitude of
medical need at major events was great; yet, at the minimum,
significant medical need was present.
Predicting the number of EMS transports in each category
is also very important. Transporting a patient from an event
to a hospital requires at least 2 event medical personnel and
the use of an ambulance for a significant period. For events
that may require several transports, this additional use of
resources places further demands on the personnel and
equipment. As minor events generate few transports, this
concern can be minimized in those circumstances. Even
many major events saw few transports, but those resources
were available when needed.
Other effects were noted anecdotally at major events,
where significant medical resources were on hand. In some
cases, the presence of highly trained medical personnel
seemed to cause an increase in patient contacts, as event goers
sought the counsel of these providers in addressing long-term
medical issues. For example, patients might approach the
medical personnel and report exertional chest pain over the
last several months. These contacts often represent legitimate
medical issues but are not the type of situation that the event
response team was established to address. Furthermore, these
situations can cause extra burden on resources that already
have to address a significant number of emergency contacts.
The presence of highly trained personnel did, however,
reduce the number of patients who required transport, in
many cases. An on-site physician provided the capability to
effectively assess patients and determine whether or not
hospitalization would be required.
Possible implications for resource allocation can be
inferred. Minor events may require only 1 transport unit,
staffed by one advanced life support (ALS) provider and one
N. Hartman et al.
basic life support (BLS) provider. Intermediate events could
be staffed by several ALS providers (1-3) and BLS providers
(1-6) staffing 2 transport units. Major events are by nature
more variable and would require multiple ALS and BLS
personnel, specialized equipment, and, in some cases,
physician presence. For large events, having a physician
staff an event has been suggested as a way to reduce the need
for medical transports [7]. In some cases, however, the
presence of a physician may prompt patients to present to
EMSs for care, thus increasing the medical demands and
EMS transports [8].
This study suffers from many of the same limitations of a
retrospective review. Details of the various encounters during
each event were not always available, although reliable data
for categorizing each encounter as minor or major were
present and adequately identified. As a review of records,
this study was retrospective, but the criteria for categorizing
events were determined a priori, before the data were
examined. The sample events used here represent a relatively
small sample size, but are representative of the types of
events routinely staffed by special events teams. Another
major shortcoming of this analysis is the inability to identify
the individual impact of each of the predictive factors. For
instance, in event planning considerations, should weather
and presence of ethanol be significantly weighted when
compared to crowd intentions and demographics? For the
purpose of this analysis, these predictive factors were all
weighted equally. Yet, the reality of event planning may
suggest that the impact of these factors should be considered
on a case-by-case basis.
5. Conclusion
Mass gatherings present an important challenge to
medical providers and event planners. Medical resources
must be deployed to these events in a thorough yet efficient
manner, based on reasonably expected needs. This study
demonstrates that stratifying mass gathering events based on
several predictive factors can effectively estimate the number
of patient contacts. Further research will be required to
develop a more precise system, but the factors used in this
classification scheme have been shown to heavily influence
volume of patient contacts and the nature of medical needs at
these events.
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