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Abstract
Context Mass gatherings such as the Youth Olympic Games require medical services for large populations with special needs specific to elite competitive youth athletes. The location of the Games in a heavily populated city with dispersed competition venues provides unique challenges.
Objective To describe the planning and delivery of medical services and to provide data for future planning.
Setting Singapore. One large multipurpose clinic was set up in the Games Village as well as medical posts at competitive venues for 26 sports for onsite coverage. Period of coverage: 10 August 2010 to 28 August 2010.
Participants A total of 1,337 medical encounters ranging from athletes to officials and volunteers who received medical care from a spectrum of medical professionals.
Major outcome measures Number of cases attended to at the Games Village medical centres and the medical posts at the competition venues, utilisation of medical services, and the pattern of these injuries and referral patterns to hospitals.
Results Medical encounters for non-athletes represented 40.9% of the total medical encounters. The rate of heat illnesses was low for athletes at 1.7% (N = 13). The total hospitalisation rate was low at 1.7% (n = 23). Utilisation of onsite pharmacy and physiotherapy services were high at 45.2% (n = 887) and 37.8% (n = 743), respectively, of the encounters for all support services.
Conclusion The dispersed nature of the Games venues provided challenges to the organisation of medical cover for the participants. Organisers in future Games can make use of the data to plan for future Games of a similar nature.
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Introduction
Mass gatherings require provision of medical services to render basic first aid as well as emergency care. The concept of the organisation of the Games is to utilise pre-existing infrastructure to support the competition and the accommodation of the local and foreign athletes and delegates. Athletes and accredited officials were housed in the Games Village while foreign delegates without accreditation were domiciled in hotels. The competitions were to run concurrently at 38 venues dispersed around the city.
Three thousand six hundred competitive youth athletes aged 14 to 18 years from 205 countries for the Youth Olympic Games (YOG) in a heavily populated city posed unique challenges in maintaining the health and medical safety for the participants. Careful planning and provision of medical resources is essential to minimise strain on the existing medical system while ensuring the public health and medical safety of the large number of athletes and affiliated officials and 2,400 volunteers. The period of medical coverage from the 10th to the 28th of August 2010 encompasses the competition period as well as the pre-competition acclimatisation training for foreign teams.
Methods
Medical attendances were classified according to accreditation status. Official participants in the Games were issued individual identification passes which allowed access to competition venues and the Games Village based on the accreditation status. Athletes were participants competing in the Games. Officials included medical personnel, coaches and trainers and administrative personnel of the various delegations. The workforce included both volunteers as well as full-time staff engaged by the Games organisers. Spectators were classified as non-accredited personnel.
Medical organisation
Medical services for the YOG were supervised by the International Olympic Committee (IOC) Medical Commission delegates and were coordinated by the YOG Medical Services Committee in conjunction with the Singapore YOG Organising Committee. The initial planning for medical services was based on prior data collected from the medical services provided for the inaugural Asian Youth Games which were held from 18 June to 9 July 2009 in Singapore and was conceptually similar in organisation. With guidance from the IOC Medical Commission, a medical service plan was formed, which included a medical centre designed to provide primary care services 24 h a day to the athletes and accredited Games officials domiciled in the Games Village. The medical centre was equipped with four consultations rooms, a physiotherapy rehabilitation area, and a diagnostic ultrasound room for the diagnosis and management of sports injuries. Additional facilities included radiology services (x-ray), laboratory services for haematological and urine analysis, pharmacy services and a dental clinic. For cases beyond the capabilities of the onsite facility, the patient was transferred to a designated YOG hospital. Express services for YOG personnel were created to expedite the registration, processing, treatment and tracking of the YOG patients in the hospital settings.
To augment the medical services, team physicians from the foreign National Olympic Committees (NOC) were accorded temporary medical registration by the Singapore Medical Council to allow them to render medical services to members of their contingent. Prescription and imaging services were extended to the team physicians and treatment areas were allocated at the dormitories for treatment by team medical personnel.
The medical evacuation plan at the competition venue involved initial on-site treatment and stabilisation of casualties followed by rapid evacuation of urgent cases to the designated hospitals. Less urgent cases were evacuated to the Games Village medical centre for investigation and further management. Medical services at each competition venue were organised into medical aid stations. Each station was equipped to handle cardiac arrests, render immediate care to urgent traumatic cases as well and provide medical assistance to minor medical problems. In total, 33 medical rooms and 86 medical posts were set up. In order to better rationalise the use of resources, the sports were categorised according to risk (Annex 1). Staff deployment were augmented in the venues that were classified as high-risk sports, where simultaneous competitions were occurring and where the fields-of-play were extensive (cycling and triathlon). At least one ambulance was deployed at each competition venue during training and competition with extra ambulances deployed on a standby in a central location. To minimise delay in evacuation, ambulance evacuation routes were planned and the emergency departments of each of the YOG hospitals were briefed on the specific sports conducted at these venues. A total of 55 first-aid posts were set up for spectators.
All evacuations from the Games venues as well as from the medical centre of the Games Village were reported to the medical operations. Cases referred to the hospital were tracked to the point of discharge or transfer to the home country. This allowed for centralised data collection and the generation of daily reports of medical encounters and resource utilisation.
The medical committee, in conjunction with the games SYGOC and the state health services, laid out pandemic contingency plans to deal with outbreaks of new strains of H1N1 and influenza virus.
The control strategies were aimed at preventing the spread of contagion from external community and spread within the YOG community. External control measures rest on early detection of cases through screening and temperature measurements at the Youth Olymics Village (YOV), games venue, hotels and border entry points.
Internal control measures include screening for cases at the points of entry of the YOV, testing of suspected cases, and isolation of confirmed cases and quarantine of cases of close contact. Twenty isolation rooms were set aside in the YOV medical centre, and work processes for institutional contract tracing within YOG premises were established.
In the event of a pandemic, temperature screening and personal temperature screening would be instituted in the hotels where YOG officials were to be domiciled. Suspected cases will be tested in YOV medical centre, and confirmed cases would be transferred to the hospitals for management.
Medical information system
A system for collecting and monitoring medical data was established to capture medical statistics for the purpose to monitoring the status of the health of the participants, to monitor adequacy of the delivery of service and to monitor for injury trends that may require further investigation. The system also allowed for the tracking of the medical status of the hospitalised patients. Medical encounters at the medical aid stations of the competition and training venues and the Games Village medical centre were logged and medical encounter forms were completed for each physician consultation. The diagnoses and disposition of all medical encounters in the medical centre where captured from classification forms with a pre-determined list of diagnoses which were completed for each encounter. Reports were generated at the end of each 24-h period and presented in daily meetings with the Singapore YOG medical service coordinators and the IOC Medical Commission.
To standardise the data collection, the medical personnel received training pertaining to the diagnosis of the sports injuries and classification of injuries prior to the Games. We encouraged timely and complete filling of the data with pre-Games briefing and visible reminders in the consultations rooms as well as an additional layer of checks by clinic assistants.
Analysis of data
The data were analysed by accreditation category: including IOC (members, staff and guests), NOC (athletes, non-athletes and team officials), international federations (members and technical officials), media, workforce, and non-accredited spectators.
The data from the medical encounters were analysed for usage patterns and the casualty rates were tracked over time. Subgroup analysis of usage patterns between NOCs, accreditation categories, referral patterns from the competition venues and Games Village medical centre and usage rates of various support services was performed.
Statistical software from Microsoft Excel was used in the collation and analysis of the data.
Results
The total number of medical encounters during the Games period was 1,337 with an average of 58 encounters per day. The peak of the medical encounters coincided with the midpoint of the Games period. Most of the medical encounters were seen during the actual competition period between the 15th and the 26th of August, averaging 91 encounters per day.
Variation in the medical attendance rates from the competition venues as well as the Games Village medical centre accounted for the majority of the variation in total medical attendance (figure 1). This suggests that the rate of attendance was influenced mainly by the competition events in progress on a particular day. Similar trends have been reported during the 2000 Sydney Olympic Games.1 By gender, the proportion of medical encounters by males was higher at 58.2%.
Total medical encounters by day-by-venue cluster.
Athletes accounted for the majority of the medical usage at 59.1% followed by the NOC at 28.9%. Nevertheless, the work force accounted for a significant minority of the attendance at 7.7%. Medical attendances were also analysed by individual NOCs. Of the top 20 NOCs with the highest ratio of medical encounters per athlete, 18 (90%) of these did not have a registered medical practitioner in their contingent. To account for the referral bias due to the difference in sizes between contingents, a mean weighted encounter rate was calculated. The mean weighted average across all contingents was 0.29 encounters per athlete. The weighted mean average of the contingents with accredited physicians was only 0.17 while that for the continents without physicians was 0.37 (table 1). The rates of medical encounters in the group with NOC doctors had a normal distribution, while that of those without NOC doctors were multi-nodal, suggesting that the team doctors helped to filter out some of the medical counters which would otherwise have presented at the Games Village medical centre (figure 2).
Frequency distribution of NOCs versus medical encounter per athlete (with/without team doctor).
Distribution of medical encounters between NOC with team doctor and NOC without team doctor
The majority (62.3%) of the medical encounters was attributed to musculoskeletal injuries (figure 3). The next most common diagnosis (12.0%) was respiratory conditions. Despite the tropical climate of Singapore, the rate of heat injury during the Games period comprised only 1.7% of the total encounters. As part of the efforts to minimise heat-related illness, the NOC medical teams had been advised on the environmental conditions prior to Games and provision for acclimatisation was undertaken to accommodate the warm climate. Advisories on hydration were broadcast to the athletes in the form of posters in the communal areas and also through electronic media to the mobile phones issued to the athletes.
Medical encounters by diagnosis and top 3 diagnosis.
Of the sports injuries, the majority were classified as ligament sprains (16.9%), muscle strains (15%) and tendon injuries (8.8%). The pattern of injuries was similar to that reported in the 1996 Atlanta Olympic Games.2 Of the sports injuries, 56% were of lower limb (most commonly involving the leg followed by the foot and ankle region) followed by 19.1% of the upper limb (shoulders being the most common anatomical site). A similar anatomical distribution has been reported in other similar international elite multi-sport events.3,–,9
Cycling accounted for the highest number of medical encounters on a per-athlete basis (0.46) followed by handball (0.339) and equestrian (0.333) (figure 4). This coincides with the classification of these sports as high risk in the initial planning stage. This contrasts with the findings during the 2008 Beijing Olympic Games, where the highest injury rates occurred in the sports of football, taekwondo and field hockey.5
Medical encounters by sport (on per-sport-athlete basis).
The majority of the cases was categorised by the treating physician as minor and were discharged after initial treatment (42%), followed by 39.8% of all encounters requiring referral to the physiotherapist for treatment. A relatively low proportion was referred to the hospital for further investigation and management. Only 1% of the total medical encounters necessitated hospitalisation, in the same order of magnitude as other major Games.4 Of these hospitalisations, the mean length of stay was 7.0 days. The longest period of hospitalisation (29 days) was due to a dissecting aneurysm in a Games official. Of those referred to the hospitals, the majority (51.8%) was athletes while the workforce (20.9%) accounted for a significant proportion of the minority. In the 1996 Atlanta Olympic Games by comparison, athletes accounted for 16.8% of the total medical encounters (2).
The competition venues accounted for 33.6% of the total referrals to hospital. In comparison, the non-competitive venues, such as those sites attended by athletes during the Cultural and Educational Program, accounted for a significant proportion (31.8%) of the hospital referrals as well.
Of the supporting medical services, the pharmacy services were the most heavily utilised followed by physiotherapist services (45.2% and 37.8%, respectively). The utilisation of radiological services was relatively low at 6.0%.
Upon conclusion of the YOG, the original records were collected from all sport venues and the Games Village medical centre and were checked for completeness of the data. Missing data were seen in less than 5% of the forms.
Discussion
The YOG presented unique challenges for the delivery of medical services:
1) Large number of participants
2) A high percentage of foreign delegates and athletes
3) Multiple events conducted over an extensive time period
4) Multiple events conducted simultaneously
5) The relatively young age and inexperience of the competing athletes
6) Decentralised competition venues
7) Multiple events in areas of high population density.
The challenge was to provide a good standard of care to the event without compromising the standard of medical care for the local population. Similar challenges were faced in the 2006 Torino Winter Olympic Games.4 Adequate, experienced staffing posed a particular challenge as the plan required the deployment of doctors with at least 3 years of experience in general surgery, orthopaedics, sports medicine or emergency medicine.
To meet these conflicting demands, the following strategy was employed:
a) Tailoring of provisions of medical services to each competition venue
b) Leveraging on existing medical infrastructure
c) Accreditation of NOC doctors
d) Utilisation of armed forces and private paramedic and ambulance resources
e) Organisation of a medical centre with services to accommodate the most commonly anticipated medical problems.
As sports injuries were anticipated to form the large majority of the medical encounters, medical staff with the relevant experience was deployed at the sports venues and the Games Village medical centre. A health information system was established to track the health and safety of the athletes and officials and daily utilisation of medical services thus allowing the redirection of resources to events and locations where utilisation of medical services was anticipated to be high.
The medical plan leveraged on the compact nature of the island which ensured proximity between the competition venues and the hospitals while the reliable and efficient transport infrastructure lent itself to rapid evacuation.
The climate of Singapore during the Games period posed a potential risk factor for heat illness to competing athletes. Pre-emptive measures such as health advisories to the athletes as well as medical pre-briefing to the NOC officials resulted in low rates of heat illnesses (1.2%). This result is similar to the low rates of heat illnesses reported among athletes in the 1996 Atlanta Olympic Games.2
The Games Village medical centre services were also heavily utilised, accounting for the 78.4% of non-repeat visit medical encounters. This suggests that the majority of the medical encounters were of a non-urgent nature, which could be treated within the medical centre, with only 5.8% requiring referral to the hospitals for further imaging or treatment. Of these, the most common reason was to seek specialist outpatient treatment (34.7%) and the second was for MRI scan (32.0%). Despite this, the total number of the latter (23 cases) was low. This low MRI utilisation statistic, along with the ease of accessibility and proximity of MRI facilities in hospital, supports the decision not to provide a temporary MRI onsite in the Games Village.
A balance has to be struck between providing a full range of medical services in competition venues and referring patients to the hospitals for non-emergency services. Factors for consideration include cost, likely rates of use of services, ease of access to the same services in the local medical system, speed of transfer and reliability of transport to these areas. The relatively low rates of referral for non-emergency services (n = 75, 3.8%) suggest that a good balance of service provision was designed.
To maximise limited resources, the medical provisions at each competition site were made according to the requirement of the individual sports which were classified according to the likelihood of injuries and likelihood of severe injuries (Annex 1). Further considerations were given to prevailing ground conditions as well as the requirements of the International Federation governing a particular sport. For instance, in triathlon, in which the fields of competition were extensive, additional medical posts and ambulances were deployed.
The current study provides useful data to support the collaboration of the NOC doctors on the usage of host medical services. The registration of NOC doctors as well as extension of the prescription services and laboratory services resulted in less reliance on these contingents on host medical services. Similar patterns of usage have been seen in the 1996 Atlanta Olympic Games.
While the bulk of the medical consultations were expected to be sports injuries, the presence of a significant proportion of the medical encounters was attributed to non-competitive areas and also non-athletic injuries. In particular, non-athletic medical encounters of the work force and NOC injuries accounted for 36.6% of the total medical encounters and for 65.2% of the hospitalisation including the two cases with the longest period of hospitalisation. Among the athletes, the hospitalisation rates were low (1%), accounting for 8 out of the 23 hospitalisations (34.8%).
The proportion of athletic to non-athletic injuries are similar to studies on other major Games2 with non-athletic and spectator medical encounters accounting for significant proportions of medical system utilisation.
Conclusion
In summary, despite many challenges in an event of this magnitude, the provision of medical services at the inaugural summer YOG held in Singapore in 2010 were well organised and provided sufficient care for athletes, visiting officials and dignitaries, while minimising the impact on the medical care for the local population. The athletes remained fairly healthy with few heat illnesses and accounted for few hospitalisations.
Acknowledgments
The authors would like to acknowledge the medical personnel who worked in the various Youth Olympic Games medical clinics and stations in addition to the members National Olympic Committee medical staff for their expertise and collaboration.
Footnotes
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Competing interests None.
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Provenance and peer review Not commissioned; externally peer reviewed.