Early involvement by health services in the planning, preparation, operations and post-event analysis of mass gatherings provides one of the best opportunities to engage with other agencies and to develop a real sense of your agency's capabilities. The establishment of the new ISO Standards on Risk Management provide the best opportunity in a decade to structure this work in a manner that will develop true capacity to manage the multitude of risks health services face this century.

Rather than ad hoc and sometimes conflicting approaches we now have the “lingua franca” on which to build our policy, capacity development, budgets and response. The evolution of risk management standards has seen the release of ISO 31000: 2009, Risk management - Principles and guidelines and ISO 31010: 2009, Risk management – Risk assessment techniques. Largely based on the earlier Australian Standard 4360 and work of the IEC these standards have the potential to embed critical aspects of the responsibilities of health agencies worldwide into a universal singular policy framework. Translating this into other areas of health agencies work includes communicable disease management and emergency management, in general, which will allow other agencies to understand the “health” perspective and vice versa.

Drawing on personal experiences from mass gatherings since 1997, the author will demonstrate the utility of the ISO Standards as the framework for health emergency management including mass gatherings. Examples will include mass gatherings at the international level within the Asia- Pacific Region to the local level within Sydney, Australia from 1997 to 2010.

During the planning phase of a mass gathering, it is important to organize the most suitable healthcare responses to assure primary, emergency, and major accident care, with the best balance between available resources and costs.

This study tries to develop a Mass-Gathering Event Risk Scoring Model (MGE-RS) to predict Medical Usage Rate (MUR) that can assist emergency medical services providers in planning for mass gatherings across a variety of events and venue types in a metropolitan area.

This study includes 48 mass gatherings in Rome (35 mass gatherings; 2005–2006) and Milan (13 mass gatherings; 2009–2010). All 35 mass gatherings in Rome had > 100,000 attendees (100,000 to 5,000,000), while the 13 mass gatherings in Milan had a median of 100,000 attendees (50,000–200,000). The median patient presentation rate (PPR) was 0.5 patients/1,000 persons: this rate is close to PPRs for mass gatherings reported in the literature (0.5–2.0 patients/1,000 attendees). For each event, the predicted MURs, calculated using the Arbon Model and the MGE-RS Model, were compared with the actual MUR. The MGE-RS scoring model uses a formula that assigns points based on known information (type of event, place, duration, crowd, health system facilities) to predict the risk. The MGE-RS score ranged from 16 to 77. There are five risk levels, each one corresponds to an expected MUR from 1.5 to 45. In the events studied, the predicted MUR calculated with the Arbon model corresponded in 60% of cases (20% under/overestimation); the MGE-RS was in range in 88% of cases (0% underestimated; 12% overestimation).

The MGE-RS seems to be a provider-friendly tool to be used in planning phase, and is able to give an acceptable estimation of the risk level and expected MUR for a mass gathering, without underestimating the estimated MUR during the planning phase.

Medical assistance for mass gathering can be classified based on the characteristics of mass gathering into primary or emergency health care for individual patient vs. medical assistance for public in case of disastrous mass gathering. It is necessary to prepare primary and emergency health care in case of routine mass gathering, but when an accident or event occurs, different medical approach will be necessary. One of the representative types of accident or event is crowd packing which can make high pressure among mass gathering participants usually from crowd rush or surge. This study was performed for identifying the characteristics of crowd packing in mass gathering.

The literature survey was performed on mass gathering and crowd packing. Human model simulation was done as a pilot study and 2-dimensional pedestrian pressure experiment was performed with volunteer students and pressure sensing device by video recording and analysis. Lateral shoulder loading and frontal chest loading were analyzed per load cell and per packed condition.

As pushing pressure increased, the body was rotated to 90 degree after some threshold pressure point. The maximal and average pressures among volunteers were extracted. Pedestrian injury criteria(PIC) curve was generated.

When crowd packing occurs, the body will be rotated about 90 degree after some threshold pressure point. And then interpersonal pressure will be increased to crush injury as crowd packing proceed. For defining the interpersonal pressure to mortality and critical injury, further research will be needed reflecting real human physiology and anatomy.

During the summer months in Australia, school leavers celebrate their end of school life at Schoolies festivals around the nation. These events are typically described as a mass gathering as they are an organised event taking place within a defined space, which is attended by a large number of people.

Two research projects were undertaken to understand the Schoolies phenomenon. The first project was to understand the event as a mass gathering. The second to determine what was important to stay safe and healthy at this event from a young person's perspective. To understand the Schoolies event as a mass gathering Arbons conceptual framework was used which considers the psychosocial, environmental and biomedical aspects of the event. This study found that the crowd mood of the Schoolies were expressive, social and participatory. The environment was bounded, ticketed and dry. The bio-medical data showed a high patient presentation rate when compared to the Australian average. However most of the presentations were minor. What was of concern to the researchers were the high level of risky drinking that took part a this event. The second study used postcards to understand what young people perceived to be important to their health and safety whilst at Schoolies. 3 lead questions were used, and 9 items placed underneath each question to be ranked by participants. Data collected showed that exposure to illicit drugs and violent behaviour where of concern to them. The results from these studies highlights the need to re focus the Schoolies event to be inclusive of strategies that not only support young people to party safely, such as dry zones, but to support young people to feel safe from exposure to drugs, and to violence (physical and sexual) that can occur for many reasons.

The addition of Tent-pegging to the 2nd Asian Beach games as one of its 14 Competition events was a welcomed step, especially to the equestrian community of the games' host country, Oman. An equestrian sport of ancient military origin with a long history in Asia, Tent-pegging It a fast-paced sport in which a lance or sword is used to pick pegs off the ground while riding a horse at full gallop. The sport is gaining popularity especially in a number of countries around the world, including Oman.

The hazards inherent in equestrian sports and specifically in Tent –pegging, furthermore, the mass gathering created by the equine presence, the participants, as well as the spectators, required a well planned medical coverage to safely conduct the games. Taking into account that Tent-pegging events normally receive limited medical support, the presentation will discuss the concepts and methods that are commonly followed by the host country on planning and implementing the medical care to sport events of Olympic standards, along with an illustration on how exclusively these concepts were applied to the Tent -pegging events during the 2nd Asian Beach Games. In addition, the presentation will elaborate on the challenges that were dealt with by the medical care providers, and the outcome following a 1st major sporting event of such a scale to be conducted by the host country, Oman. As more countries bid to host major sport events for their first time, suggestion for improving the methodology of providing medical coverage to a sport event will be discussed in the presentation.

Decision-making is the major component in triaging emergency department patients. Influencing factors on decision-making have been identified but it`s not clear how much of the decision is based upon scientific criteria. The objective of this study was to determine frequency of using reliable and valid guidelines by nurses in emergency departments.

It was a descriptive survey study. The questionnaire was composed of demographic data, evidence-based triage questions (15) and triage decision-making questions (10). The questionnaire reliability was 0.87 using the test-retest method. Content validity was considered based upon Canadian Triage and Acuity Scale.

70 nurses from 10 emergency departments participated. 40 % of nurses` responses to evidence-based questions was correct. The percentage of inter-rater agreement between nurses was moderate (0.56) related to decision-making questions. No valid and reliable guideline was utilized in emergency departments.

Nurses` decision-making was poorly based on evidence-based criteria. Low level of nurses` knowledge about triage may be derived from lack of official and specialized triage training courses. Academic triage courses establishment and development of national triage scale are recommended.

India is one of the most flood prone countries in the world, flooding annually about 9 million hectares and accounting for one-fifth of global flood deaths. Approximately 56.5 % of flood-affected Indians live in Bihar. Out of 38 districts in Bihar, 22 are flood prone, including Begusarai. The life line to the community is the Primary Health Center (PHC) which is at stake during a disaster such as floods.

To study the status of primary health care in rural parts of Begusarai during recurring floods, a survey was undertaken to analyze the preparedness and response mechanism at various hospital levels. The status of rural hospitals during a flood was represented by a case study on the PHC of Bakhri block of Begusarai district. To determine the prevailing situation during floods, the chief medical officers of each level of health care centers were interviewed.

The PHC of Bakhri caters to a population of about 408,896, which is four times the normal load for a PHC. In 2007, it was affected severely by flooding from the Baghmati River. The PHCs that were studied perennially face a shortage of human resource and infrastructural support. This is compounded by unsafe locations and structural hazards associated with the hospital building, rendering the working conditions unsafe for the medical team during disasters.

This paper envisages the functionality and challenges of healthcare providers during floods despite their limited available resources. The prevailing case scenario demonstrates the challenges in rural India, and the best practices for safe rural hospitals in coping with disasters in a resource-poor setting will be discussed.

Hospitals are highly complex facilities that play a key role in the medical response to disasters. However, they are susceptible to the impact of disasters with respect to their structural, non-structural and functional elements. Many hospitals have collapsed or been damaged and rendered nonfunctional as a consequence of disasters. The resilience of a hospital along with the capability of effective medical response to disasters is a key part of a community based disaster plan.

The objective of this study was to evaluate and compare hospitals in Iran with respect to safety.

This study was performed as a survey in four hospitals in Iran. The Hospital Safety Index package from WHO was used as an evaluation tool. The evaluation team consisted of: a PhD in structural engineering, an architect with a Master's degree, a specialist in electrical and mechanical maintenance, a medical doctor, a specialist in disaster management, and an expert in health care planning. The hospitals were evaluated in three elements; structural, non-structural, and organizational. The hospital safety calculator was used.

The most important hazard for these hospitals was earthquakes. The structural safety at three hospitals was inadequate or at risk; and consequently needs intervention in a near future. Also, the administrative and organizational element of these hospitals was inadequate or at risk. All hospitals need intervention in the near future due to non-structural safety being inadequate. The overall safety index at one hospital was A (functional); in two hospitals B (at risk); and in one hospital C (inadequate).

The Iranian hospitals which had been assessed were on the whole unsafe. Also, these hospitals do not have a disaster management plan. Implementing a comprehensive disaster plan, including mitigation and a preparedness plan, would most likely enhance the safety of these hospitals.

As the number of disasters caused by natural and non-natural hazards increase, so does the emphasis placed on healthcare security planning for the influx of patients that often accompany such events. This presentation expands on a previously published examination of national healthcare security systems and emphasizes the role of security in the hospital environment during disasters in China, India, and Japan. National emergency preparedness planning systems and disaster type are examined. Elements of planning for a mass-casualty incident (MCI) that most directly impact security planning include mass-notification alert systems, patient routing processes to hospitals (from an MCI scene) and within hospitals (emergency department flow), staffing, disaster triage, patient identification, tracking and discharge, volunteer tracking, and the adaptability and flexibility of space and processes.

Researchers conducted extensive literature reviews of country-specific health care and physical security elements of patient surge. The comparative analysis was augmented by communication with national healthcare security experts.

Positive associations exist between increased disasters and the level of priority and funding given to healthcare security measures in disaster planning. National characteristics of governance, landmass, disaster history, and population influenced the development of healthcare security systems and planning for patient surge incidents. Planning for the mental health impact of terrorism victims, and its subsequent impact to patient surge into hospitals was more relevant in the literature for both India and Japan.

Israeli Hospitals are required to maintain a high level of emergency preparedness.

To investigate the effect of on-going use of an evaluation tool on acute-care hospitals' emergency preparedness for mass casualty events (MCE).

Evaluation of emergency preparedness for MCE was carried out in all acute-care hospitals, based on an evaluation tool consisting of 306 objective and measurable parameters. Two cycles of evaluations were conducted in 2005 to 2009 and the scores were calculated to detect differences.

A significant increase was found in the mean total scores of emergency preparedness between the two cycles of evaluations (from 77.1 to 88.5). An increase was found in scores for standard operating procedures, training and equipment, but the change was significant only in the training category. The relative increase was highest in hospitals that did not experience real MCE.

This study offers a structured and practical approach for ongoing improvement of emergency preparedness, based on validated measurable benchmarks. An ongoing assessment of the level of emergency preparedness motivates hospitals' management and staff to improve their capabilities and thus results in a more effective response mechanism for emergency scenarios.

Utilization of predetermined and measurable benchmarks allows the institutions being assessed to improve their level of performance in the evaluated areas. The expectation is that these benchmarks will allow for a better response to actual MCEs. The study further demonstrated that even hospitals without “real-life” experience can gear up using preset benchmarks and reach a high standard of mass casualty event preparedness.

Hospitals handle numerous tasks whose fundamental purpose is to provide medical treatment. Amongst these, the hospital prepares for the treatment of trauma patients who have been involved in car accidents, injuries at work and industrial accidents. These preparations, although part of the operative conventions of the hospital, do not guarantee the ability to handle Mass Casualty Events which require unique and dedicated preparation and a different operational approach. This paper presents the hospital approach of handling Emergency Mass Casualty Events.

The preparations require involvement of a national level that must participate in the definition of the activities, task assignment and preparation of an annual plan. The peak of the preparations is a multidisciplinary drill, implemented as part of the annual activity of the hospital.

In an emergency situation, the aim is for the hospital staff to be capable of providing its patients (and family members) the best professional care in any given scenario. To achieve the above, the hospital is required to perform the following tasks: Defining procedures, personnel training, logistics infrastructure, control, drills and lesson learned implementation. The tasks should be performed under a multi-annual plan that covers various Mass Casualties Events scenarios including: a train accident, an event involving dangerous industrial materials (e.g. ammonia spill), biological scenarios (e.g. bird-flu) and radiation events (e.g. nuclear reaction).

Only precise preparations, disconnected completely from the on-going hospital routine can answer the need to handle Mass Casualties Events.

WHO Regional Office for Europe - Health Systems Crisis Preparedness Assessment Tool Bayer CP, Rockenschaub G.

Health crises are often unpredictable and may occur at any place or time. Communities are particularly vulnerable when local and national systems, specifically health systems, are unable to cope with the consequences of a crisis, usually because they are overwhelmed by a sudden increase in demand or because the institutions that underpin them are fragile and cannot deliver what is required. The World Health Organization (WHO) Europe Health System Crisis Preparedness Assessment Tool aims to provide guidance to ministries of health and other relevant authorities on evaluation and strengthening of their health system's capacities for crisis management.

Based on an all hazard approach, an assessment tool was developed which comprises essential attributes considered vital for countries to meet the challenges of future health crises. The foundation of the tool derived from expert consultation workshops and pilot testing in eight countries in the WHO European Region.

The tool lists essential attributes with respective indicators crucial for evaluating and identifying gaps in health system crisis preparedness. The assessment tool is structured according to the six building blocks of the WHO health system framework and is complemented by a user manual, allowing countries to apply a self–assessment approach. The tool is intended for use by ministries of health or other relevant institutions.

The tool may help determine the current status of health system crisis preparedness and facilitate the development of a prioritized plan of action that addresses any gaps identified. When used regularly the tool will help monitor progress.

Hospitals play a critical role in communities to provide essential medical care during all types of disaster. Depending on their scope and nature, disasters can lead to rapidly increasing service demand that can overwhelm the functional capacity and safety of hospitals and the health care system at large. The World Health Organization (WHO) Regional Office for Europe All-Hazard Hospital Emergency Preparedness Checklist aims to assist hospital administrators and disaster managers in preparing health facilities to respond effectively to the most likely disaster scenarios.

A checklist tool was developed that comprises current hospital-based emergency management principles and techniques, and integrates applications specific to hospital preparedness needs in the WHO European Region.

A list of recommended actions within critical service categories is provided in a step-wise, all-hazard form for rapid implementation by hospital administrators and disaster managers in response to the most likely types of disaster.

The principles and recommendations provided in this tool may be used by hospitals at any level of emergency preparedness. The checklist is not intended to replace standards and protocols already defined in hospital emergency management plans. Rather, it provides recommendations to enhance existing plans in concert with national guidelines.

The Hospital Preparedness Program, prompted by the 9/11 terrorist attacks, emphasizes the value of developing coordinated response capabilities by community leaders. Immediately following Hurricanes Katrina and Rita, this study examined the hospital emergency preparedness coordinators' leadership style and applied leadership theory to Louisiana planners as an integral part of a complex National Response Framework. This regionally coordinated system remains in place today and has been tested a minimum of 15 times in hurricane activations and state-wide exercises and drills.

Three hospital groups participated: (1) regional coordinators representing nine geographic areas; (2) coordinators at acute care facilities; and (3) coordinators at non-acute care facilities. A total of 744 study participants represented over 150 hospitals. The Multifactor Leadership Questionnaire (Bass, 1995) assessed three dimensions of leadership style and the Emergency Preparedness Indicator assessed planning priorities, performance ratings, demographic variables of gender, education, and Healthcare Performance Partners (HPP) planning experience and disaster declarations.

Transformational leadership was highest among all three groups and included characteristic of: idealized influence, idealized behaviors, inspirational motivation, intellectual stimulation, and individual consideration. Transactional leadership was highest (but still lower than transformational) among the non-acute care group and included characteristics of: contingent reward and management by exception (both active and passive). Gender and education were not significant predictors of leadership style but positive associations of time spent on emergency preparedness activities were found.

Previous studies reported the relationship of transformational leadership style to cohesion scores of 2.1. This study expands those results by further detailing leadership styles to the hospital emergency preparedness coordinator. It builds on a standardized approach to assess coordinator leadership style and effectiveness measures.

Immediately following a major public health emergency or complex humanitarian emergency such as the South East Asian Tsunami in 2004, the Haitian Earthquake in 2010 or Hurricane Katrina in 2005, there is a critical need to rapidly and as accurately as possible gather information not limited to morbidity and mortality, but necessary to assess the stability and existence of a public health or medical infrastructure, logistic supply chain, condition of food, water and shelter for victims and rescue workers, and particularly the security and stability of the region following the incident. With this information, only then can an effective humanitarian response be planned and executed that meets the actual versus perceived needs of an affected population.

Specific disaster risk assessment and medical intelligence techniques will be presented that are currently used by a variety of relief organizations. Specific topics of discussion include: Disaster epidemiology; Indicators of health in populations; Systems of surveillance; Impact of weather and climate; Displaced populations and refugee health; Tactical and combat medical intelligence; Zoonotic diseases; Agricultural trends and food security; Public health and health system infrastructure assessment; and Personal and physical security concerns.

Utilizing case reports, best-practices and lessons learned from numerous international humanitarian responses, this session will guide participants though the performance of a rapid disaster assessment and the gathering of critical medical intelligence to determine the kinds and types of resources needed in an affected area. And the process of utilizing limited information to plan humanitarian relief efforts.