NARRATIVE

Centrale Operativa 118 Area Omogenea Emilia Est EMS provides assistance every year to a series of MGEs in the area of Bologna, such as street parades, football matches, and concerts with up to over 40000 participants. The management of an international event offered an opportunity to experiment with a different approach in the EMS organization.

The Union of European Football Associations’ (UEFA) Under-21 tournament, which held from June 10 to 27, 2019 required emergency medical assistance during 4 official soccer matches. All matches were held at the municipal stadium Renato Dall’Ara, with a total capacity of 32000 seated spectators. The number of spectators for the 4 matches was 72655, with almost full occupancy of the stadium during the Italian football team matches. Total attendance, including stadium staff and other on-site workers such as police officers and firefighters (minimum of 757, maximum of 882), was 76030.

The on-site medical resources were structured on the Maurer algorithm, as stipulated by the Italian law on MGE organization.^{Reference Neri6} Medical assistance in the stadium involved 68 operators for each match. The emergency department of Maggiore Hospital, a tertiary emergency trauma centre, is located a distance of 2.3 kilometers away.

Patient Presentation Rates (PPR), calculated over the total attendant number, ranged from 0.11 to 1.35, with a mean value of 0.41; the majority of patients suffered minor illnesses or injuries, and were treated within the venue. Mean Transport To Hospital Rate (TTHR) was 0.08 (min 0.04, max 0.12); one patient was transported to the hospital for a severe traumatic brain injury after a fall from the stands. The detailed data are reported in Table 1.

TABLE 1 Event details

Staff included stewards, players, and team staff, European and Italian soccer federations personnel, referees, volunteers, police officers, firefighters, and medical teams.

PPR and TTHR have been calculated from the total attendant number (participants + staff).

Abbreviations: PPR, Patient Presentation Rate; TTHR, Transport to Hospital Rate

This field report describes patient presentation, environmental features, organization, and usage of emergency medical resources and personnel during the UEFA matches held in Bologna in June, 2019. Data were collected in an electronic database by the nurse coordinator of each event, and subsequently analyzed in an Excel spreadsheet, version Office Professional Plus 2019 (Microsoft Corporation, Redmond, WA), presenting basic statistical variables (mean values and percentages). Standardized measures were calculated as follows: PPR - patients presenting per 1,000 spectators, and TTHR - patients transported to hospital per 1,000 persons in attendance. Heat Index (HI), representing the ‘perceived temperature’ based upon temperature and humidity, was calculated with an online calculator provided by U.S. National Weather Service (https://www.wpc.ncep.noaa.gov/html/heatindex.shtml).

Institutional EMS in Bologna is historically based upon a collaboration with the local area volunteer ambulance associations. The different resources (physicians, emergency nurses, and volunteer rescuers) deployed for standard emergency medical assistance during football matches were calculated using the Maurer score and the historical experience developed during local football championship matches. The number and type of personnel were adapted according to our EMS organization, using teams of 4 rescuers instead of 3, to ensure safe transport with stretchers from the stands, and using emergency nurses as an intermediate level of care. The Arbon score overestimated in 3 matches, and underestimated in one, the number of participants who effectively requested medical intervention.^{Reference Arbon7}

In addition to medical assistance during the game, it was necessary to guarantee an adequate number of personnel in the streets surrounding the stadium, closed to traffic, where people waited for the opening of the gates between food stands and merchandise shops. Two ambulance spots and two bicycle responder teams, each comprising a nurse and a volunteer rescuer with E-bikes equipped with AED and medical devices, were planned for quick responses over an optimal coverage of a 9.5 square kilometer pedestrian area. During the game, medical resources were deployed into the stadium as follows:

• 10 Basic Life Support (BLS) teams of 4 volunteer rescuers over the stands (equipped with scoop stretchers, AED and emergency backpacks);

• 2 teams of 4 operators at the base of the stands (equipped with wheeled stretchers to transport patients to the medical posts);

• 2 ambulances with 1 emergency nurse and 1 emergency physician, located at the two sides of the stadium (equipped with emergency and resuscitation equipment);

• 1 team (1 emergency nurse and 3 volunteer rescuers) and 1 Advanced Life Support (ALS) team (1 emergency physician, 1 emergency nurse, and 1 rescuer) for intervention within the pitch.

E-bike teams were available in the inner ring of the stadium and ensured rapid intervention by an emergency nurse. This type of organization allowed every patient rescued by volunteers over the stands, to be promptly evaluated by a nurse and if necessary accompanied to the physicians’ stations.

PPR during the UEFA Under -21 championship in Bologna was comparable to previously described international experiences. Analysis of the environmental elements of the 4 matches showed a positive relationship between elevated temperature and HI, as recorded during match 4 (Germany-Romania, 31°C, and 34 HI), with an increased PPR, three times higher than the average of the whole set of matches. Ironically, we can hazard that when free water is not available, patrons prefer to spend their money buying beer rather than bottled water. Absence of free water and increased alcohol consumption due to the hot weather may have contributed to a greater request for medical intervention. Most of the patients were visited and treated in the medical facilities in the stadium.

LIMITATIONS

High level evidence studies on MGE are difficult to realize and this report only aims to describe our experience in managing this series of events while reporting standardized measures such as PPR and TTHR.^{Reference Ranse and Hutton8} The limitations mainly stem from our small sample size from a limited series of events, (only four football matches) where the number of patients assisted in medical emergencies or transported to the hospital was relatively low, even if in accordance with literature findings.