Medical demand and emergency resource utilization during international rugby matches at a high-capacity stadium: a retrospective observational study

Medical demand and emergency resource utilization during international rugby matches at a high-capacity stadium: a retrospective observational study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Medical demand and emergency resource utilization during international rugby matches at a high-capacity stadium: a retrospective observational study Antonio Gulli', Mariagiovanna Caporale, Flavio Figuretti, Giordana Tiberi, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9289954/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 15 You are reading this latest preprint version Abstract Background To describe medical activity, emergency resource deployment, and patient outcomes during international rugby matches held at a high-capacity stadium. Methods We conducted a retrospective observational study of all medical encounters recorded during seven international rugby matches held at the Olympic Stadium (Rome, Italy) between 2023 and 2025. Event risk assessment and medical planning were performed using a standardized mass-gathering risk stratification approach. Patient Presentation Rate (PPR) and hospital transport rate were calculated per 10,000 attendees. Results Across the seven matches, 451,934 individuals were present at the venue. A total of 162 medical encounters were recorded, corresponding to a PPR of 3.6 per 10,000 attendees. Most presentations were of low acuity, with 86 white-code (53.1%) and 60 green-code (37.0%) cases. Higher-acuity events were uncommon (13 yellow-code [8.0%] and 3 red-code [1.9%]). Twelve patients (0.3 per 10,000) required hospital transport, while 14 refused transfer after on-site assessment. Medical deployment included physicians, anaesthesiology–intensive care specialists, nurses, first responders, advanced life support units, and mobile response teams, ensuring comprehensive on-site coverage. Conclusions Despite formal classification as moderate-to-high risk, medical demand during international rugby matches was low and predominantly consisted of minor presentations. Extensive on-site EMS deployment enabled effective management of medical events and minimised hospital transport. These findings support the potential value of structured, redundancy-based medical models for large stadium-based sporting events. Mass gatherings Emergency medical services Rugby Stadium medicine Patient presentation rate Sports medicine Figures Figure 1 Figure 2 KEY MESSAGE What is already known on this topic Mass-gathering sporting events require structured medical planning yet reported patient presentation rates vary widely depending on event type, venue structure, and environmental factors. Detailed data from European rugby stadiums remain limited. What this study adds This study provides comprehensive real-world data from seven international Six Nations matches, demonstrating a low patient presentation rate (3.6/10,000) and infrequent hospital transport despite moderate-to-high formal risk classification. How this study might affect research, practice or policy These findings suggest that highly structured stadium environments with integrated command systems may experience lower-than-anticipated medical demand, supporting refinement of risk stratification tools and resource allocation models for large sporting events. BACKGROUND Mass-gathering sporting events pose unique challenges for medical planning, delivery, and coordination. International rugby competitions attract tens of thousands of spectators, often within stadiums of high capacity and complex logistical constraints, markedly different from dispersed events. Ensuring adequate medical preparedness is essential to minimise risks, provide timely care, and reduce unnecessary hospital transports. 1,4 Spectator medicine has been described in various contexts, including football World Cups, Olympic Games, and more recently the Rugby World Cup 2019 in Japan, where most presentations were minor and strongly influenced by environmental, organizational and crowd-related factors. 4,7 However, published data for European rugby venues remain limited. The Six Nations Championship represents one of the most important annual rugby tournaments worldwide and provides an opportunity to evaluate a structured, risk-based, medical model in a high-capacity stadium. Rome hosts Italy’s home matches at the Olympic Stadium (Rome, Italy), a venue with a maximum capacity of approximately 70,000 spectators. This study provides the first comprehensive evaluation of spectator medical activity during seven Six Nations matches held between 2023 and 2025. Our objectives were to: describe the volume and type of medical presentations; assess severity distribution and hospital transport rates; and compare indicators with previously published international experiences. MATERIALS AND METHODS This retrospective observational study analysed medical activity recorded during all international Six Nations rugby matches hosted at the Olympic Stadium between 2023 and 2025. The Olympic Stadium is a multi-purpose, all-seater stadium with controlled access and a maximum capacity of 69,689 spectators, excluding surrounding areas. Seven matches were held during the study period, and all eligible events were included; therefore, no formal sample size calculation was performed. The Six Nations is an annual international rugby union tournament held over five weekends between February and March, involving the national teams of England, France, Ireland, Italy, Scotland, and Wales. All Italian home matches are played at the Olympic Stadium. Across the seven matches included, mean ambient temperature was approximately 12°C, consistent with the winter–early spring season. Rainfall occurred during four matches without thunderstorms, and weather conditions remained within predefined operational safety thresholds. Medical organization and emergency preparedness For each match, a comprehensive on-site emergency medical service (EMS) was deployed to ensure advanced life support coverage for both spectators and players. Medical teams included physicians, anesthesiology–intensive care specialists, nurses, trained first responders, and ambulance drivers. Medical resources comprised fixed medical posts, mobile response units, pitch-side ALS (Advanced Life Support) teams, and advanced life support ambulances positioned both inside and outside the stadium. Athlete-specific emergency preparedness was ensured through dedicated pitch-side ALS teams and a fully equipped players’ Emergency Room (ER) located within the athletes’ area. The players’ ER was staffed by ALS-trained physicians and nurses and equipped with advanced monitoring, resuscitation, airway management, trauma care devices, and diagnostic tools, including point-of-care ultrasound and mobile digital radiography (Fig. 1 ). A dedicated Head Injury Assessment (HIA) station with integrated video review and neurological testing facilities was also available. Risk assessment and medical planning Event risk assessment and healthcare planning were conducted in accordance with national guidelines for medical assistance at planned events and mass gatherings, as defined by the Italian State–Regions Agreement of 5 August 2014 and its subsequent implementation decree 5 8 . Event risk was quantified using standardized scoring tables incorporating event-related and audience-related factors (Supplementary materials, Table 1 ). The cumulative score determined the overall event risk classification (Supplementary materials, Table 2 ). Based on the resulting risk classification, the type and number of medical and emergency resources required were defined using the Maurer algorithm, a structured mass-gathering risk stratification tool that translates event risk into predefined staffing levels and medical resource allocation. 9 Detailed scoring tables and regulatory references are provided in the Supplementary Material. All matches held during the study period were classified as moderate-to-high risk. Medical system organisation Spectator medical care was delivered through a structured, multi-layered network of medical posts fully integrated within the Stadium Safety Operations Group and operating under a unified command–control–communication framework. This organisation enabled real-time coordination between medical teams, stewards, safety officers, and the regional emergency medical service (Regional Emergency Medical Service, ARES 118), ensuring rapid identification, dispatch, and escalation of medical responses throughout the stadium. In addition to the central medical room and pitch-side advanced life support teams, the Olympic Stadium was equipped with an extensive spectator-oriented medical network designed to ensure rapid and redundant access to care across all seating areas and crowd densities. The in-stadium system included ten first-aid stations distributed across the main spectator sectors and four medical towers, ensuring comprehensive horizontal and vertical coverage of the venue. This configuration was specifically intended to reduce response times and facilitate care delivery in upper-tier seating areas, where evacuation times may be prolonged. Each of the four medical towers was staffed with a dedicated ALS physician (anesthesiologist–intensivist), providing immediate advanced life support capability at elevated seating levels. An additional ALS physician was assigned to the VIP and authorities’ stand, ensuring dedicated advanced care coverage for high-profile seating areas. The ten first-aid stations were organised as dual-component units, consisting of a first responder team operating directly within the spectator stands and a medical team stationed in an adjacent medical room. This configuration allowed parallel management of on-site assessment and definitive care. All first-aid stations were staffed with physicians, nurses, and trained first responders. Two stations, located at opposite ends of the stadium, were further reinforced with an ALS physician to provide additional redundancy in geographically distant sectors. Each first-aid station and medical tower was equipped with essential emergency equipment, including oxygen supply, automated external defibrillators, immobilisation devices, and basic trauma and medical supplies. To extend medical coverage beyond the stadium perimeter, two external first-aid posts were established in the main ingress and egress areas. Each external unit consisted of a medical tent equipped with two treatment beds, a dedicated ambulance, and a medical team including an ALS physician, a nurse, and an ambulance driver. These posts managed medical presentations occurring during pre-event access, post-match crowd dispersal, and within designated post-event social areas (“third half”), where alcohol consumption and minor trauma are more frequent. The integration of internal and external medical posts within the GOS structure facilitated early interception and treatment of non-severe conditions, efficient escalation of critical cases, and optimisation of medical resource utilisation, while maintaining continuous situational awareness and immediate ALS availability across the venue. Data collection and documentation All medical teams were equipped with standardized paper-based medical encounter forms used for real-time documentation during each intervention. For every medical presentation, personnel systematically recorded the date and time of the event, stadium sector or location, primary symptoms or reason for presentation, assigned triage severity code (white, green, yellow, or red), vital signs when clinically indicated, administered treatments, and outcome of the medical encounter (on-site resolution, hospital transport, or refusal of transport). Paper forms were completed contemporaneously at the point of care and subsequently reviewed and entered a dedicated anonymized database for retrospective analysis. This standardized documentation process ensured consistency across all medical posts, mobile units, and pitch-side teams, allowing reliable aggregation of clinical and operational data across matches. All medical encounter forms were complete for the variables analysed, and no missing data were identified. This study analyzed routinely collected anonymized data from all spectators requiring medical attention during the study period. No exclusions were made based on sex, gender, ethnicity, socioeconomic status, disability, or other protected characteristics. The study team included clinicians with expertise in emergency medicine and mass-gathering medical planning. Given the retrospective design, no direct patient or public involvement was feasible. According to national regulations, formal ethics committee approval and individual informed consent were not required for retrospective analyses of anonymized service data. Outcomes Patient presentation and hospital transport rates were calculated per 10,000 individuals present at the venue, in line with commonly used metrics in mass-gathering medicine. 10 The population at risk included spectators, school groups, and accredited staff physically present at the stadium. Secondary outcomes included triage severity distribution, hospital transport rate per 10,000 attendees, refusal of transport, and descriptive reporting of medical resource deployment. Statistical analysis Descriptive statistics were used to summarise medical encounters, triage severity, and resource utilisation. Continuous variables are reported as means with standard deviations, as appropriate. Categorical variables are presented as counts and percentages. Patient presentation and hospital transport rates were calculated per 10,000 individuals present at the venue with 95% confidence intervals calculated using exact Poisson methods. RESULTS Attendance and population at risk Seven international Six Nations rugby matches were included in the analysis. Across these events, the total number of individuals physically present at the venue, including spectators, school groups, and accredited staff, amounted to 451,934. This number was used as the population at risk for all subsequent analyses, as all categories were potentially exposed to on-site medical services. Event risk assessment classified the event as moderate-to-high risk. Accordingly, and in line with the Maurer algorithm, a structured medical and emergency response plan was implemented. The deployed resources included a dedicated Medical Service Director (anesthesiologist/intensivist), a resources and logistics coordinator, 10 physicians with an additional physician assigned to the third-half area, and 12 anesthesiology and critical care physicians distributed across the field of play, athlete-dedicated areas, and third-half facilities. The healthcare team further comprised 38 nurses, 38 first responders, and 14 ambulance drivers. Advanced life support coverage was ensured by 12 ALS units strategically positioned inside and outside the venue, complemented by two on-field electric medical micro-cars. Additional support included two sanitization teams and two coordination units to ensure operational continuity throughout the event. Table 1 summarises the medical and emergency resources deployed per match, both overall and normalized per 10,000 spectators. Table 1 Medical and emergency resources deployed per event and per 10,000 spectators Resource Deployed per event Per 10,000 spectators* Medical Service Director (Anesthesiology/ICU) 1 0.15 Logistics and resources coordinator 1 0.15 Physicians, total 22 3.4 – Anesthesiology / Critical care physicians 12 1.8 – Other physicians 10 1.5 Nurses 38 5.8 First responders 38 5.8 Ambulance drivers 14 2.2 Advanced Life Support units 12 1.8 On-field medical micro-cars 2 0.3 Fixed medical posts / towers 14 2.2 External first-aid posts 2 0.3 Sanitization teams 2 0.3 *Per 10,000 spectators, assuming an average attendance of approximately 65,000 spectators per match. Figure 2 shows the disposition of the ambulances at the Stadium. Medical encounters and triage severity During the study period, a total of 162 medical encounters were recorded, corresponding to a mean of 23 (± 6.4 SD) interventions per match. Triage severity codes were predominantly of low acuity, with 86 white-code cases (53.1%) and 60 green-code cases (37.0%), while higher-acuity presentations were less frequent, including 13 yellow-code cases (8.0%) and 3 red-code cases (1.9%). Among the 162 medical encounters recorded across the included matches, 12 patients (7.4%) required hospital transportation and admission. In addition, 14 patients (8.6%) refused hospital transfer after on-site medical assessment and clinical stabilisation. The remaining cases were managed entirely on site without the need for hospital referral. The Patient Presentation Rate (PPR) was calculated as the number of medical presentations per 10,000 attendees, using the total number of individuals physically present at the venue—including spectators, school groups, and accredited staff—as the denominator (n = 451,934). Overall, the PPR was 3.6 per 10,000 attendees (95% CI 3.1 to 4.2). Severity-specific PPRs were 1.9 per 10,000 (95% CI 1.5 to 2.4) for white-code presentations, 1.3 per 10,000 (95% CI 1.0 to 1.7) for green-code presentations, 0.3 per 10,000 (95% CI 0.15 to 0.49) for yellow-code presentations, and 0.1 per 10,000 (95% CI 0.01 to 0.19) for red-code presentations. The hospital transport rate was 0.27 per 10,000 attendees (95% CI 0.14 to 0.46). Low-acuity presentations therefore accounted for most medical encounters, while high-acuity events were rare. Table 2 Match-level spectator medical activity and Patient Presentation Rate (PPR) Match date Attendance White code Green code Yellow code Red code Total encounters PPR 8/2/2025 63018 7 6 4 1 18 2.9 23/2/2025 68276 17 12 1 0 30 4.4 15/3/2025 71981 22 9 1 1 33 4.6 3/2/2024 59500 9 11 2 1 23 3.9 9/3/2024 72189 9 5 2 0 16 2.2 25/2/2023 53234 9 13 2 0 24 4.5 11/3/2023 63736 13 4 1 0 18 2.8 Total 451934 86 60 13 3 162 3.6 Mean 64562 12.3 ± 5.5 8.6 ± 3.5 1.9 ± 1.0 0.4 ± 0.5 23.1 ± 6.4 Type of medical presentations Medical presentations were predominantly related to trauma, which accounted for 64 cases (39.5%). Cardiovascular complaints were the second most frequent cause (23 cases, 14.2%), followed by neurological symptoms (11 cases, 6.8%). Gastrointestinal disorders (9 cases, 5.6%), alcohol-related presentations (10 cases, 6.2%), and allergic reactions (7 cases, 4.3%) were less common. Respiratory complaints (2 cases, 1.2%) and glycaemic disturbances (1 case, 0.6%) were rare. No isolated panic attacks were recorded. In addition, 35 presentations (21.6%) involved mixed or non-specific symptoms requiring combined clinical assessment. Of the 162 medical encounters recorded, 30 (18.5%) concerned accredited staff members. Overall, most medical encounters were related to minor trauma or transient medical conditions. DISCUSSION This study provides a comprehensive evaluation of spectator medical activity during international Six Nations rugby matches held at a large European stadium, formally classified as moderate-to-high risk according to the Maurer algorithm. Despite a formal moderate-to-high risk classification, the observed medical workload corresponded to fewer than four medical encounters per 10,000 attendees and fewer than one hospital transport per 30,000 attendees. These results suggest a potential discrepancy between the anticipated risk level derived from standardized mass-gathering risk stratification tools and the actual medical demand observed during international rugby matches held in a highly structured stadium environment. In line with this observation, previous reports from large European stadium events have similarly described a predominantly low medical workload, largely composed of minor conditions, despite substantial levels of medical preparedness. 11 Similar patterns of low clinical workload despite high levels of preparedness have been reported during other large sporting events, including the Rugby World Cup 2019 and the Ryder Cup 2023 12 . The observed PPR is consistent with, or slightly higher than, values reported during other international rugby events, such as the Rugby World Cup 2019 in Japan (2.63/10,000), and markedly lower than those reported for other mass-gathering sporting events characterised by prolonged exposure, outdoor mobility, and environmental stressors, such as the Ryder Cup 2023 (16.5/10,000). These comparisons highlight the influence of event typology and venue structure on medical demand. 6, 12 Notably, most medical presentations were of low acuity, with white- and green-code cases accounting for more than 90% of encounters, and fewer than 8% of cases requiring hospital transport. This pattern suggests that, in highly structured stadium environments with controlled access, seating, and crowd movement, generic mass-gathering risk stratification tools may conservatively overestimate the expected clinical workload, while still appropriately identifying the potential for high-consequence events. Importantly, despite the overall low medical workload, the deployed medical system proved capable of managing rare but high-acuity emergencies. During the study period, red-coded events included an out-of-hospital cardiac arrest with successful resuscitation and favourable neurological outcome, an acute myocardial infarction, and a ruptured abdominal aortic aneurysm, all managed on site with prompt advanced care and associated with good clinical outcomes. The low incidence of severe medical events observed in this study likely reflects both contextual and organisational factors. From an environmental perspective, the winter–early spring timing of the Six Nations may have reduced heat-related illness and dehydration. From an organisational standpoint, the extensive, redundancy-based medical deployment—including widespread first-aid stations, medical towers with on-site anaesthesiologist–intensivists, pitch-side ALS teams, mobile response units, and a fully equipped players’ Emergency Room—enabled rapid assessment, early treatment, and efficient triage of medical presentations. Importantly, the integration of all medical resources within the Stadium Safety Operations Group and a unified command–control–communication framework ensured real-time situational awareness and coordinated response across the venue. This integrated approach likely contributed to early interception of non-severe conditions, minimised secondary crowd movement, and reduced unnecessary escalation to hospital-based emergency services. Taken together, these findings support the potential value of a structured, redundancy-oriented medical model for large stadium-based sporting events. While resource-intensive, such an approach appears to ensure both safety and system resilience, allowing rapid response to critical incidents while maintaining efficient management of the large volume of minor presentations typically encountered in spectator medicine. Limitations This study has several limitations that should be acknowledged. First, its retrospective observational design relies on routinely collected medical data, which may be subject to incomplete documentation or reporting variability despite the use of standardized paper-based medical forms and structured triage protocols. However, the uniform documentation framework applied across all medical posts and mobile teams was intended to minimize heterogeneity in data collection. Second, the analysis was conducted at a single venue, the Olympic Stadium in Rome, and reflects the organizational model, crowd characteristics, and environmental conditions specific to this setting. While the findings are likely generalizable to other large European rugby stadiums, caution is warranted when extrapolating results to different sports, venues, or healthcare systems. Third, follow-up data were not available for patients transported to hospital or for those who refused transport. As a result, downstream clinical outcomes could not be assessed, and the study focuses exclusively on on-site medical activity and immediate disposition. Finally, although all matches were classified as moderate-to-high risk according to the Maurer algorithm, medical demand was influenced by contextual factors such as winter–early spring climate and controlled stadium access, which may have contributed to the low incidence of heat-related illness and severe presentations. These factors should be considered when comparing patient presentation rates with events held in different environmental or seasonal conditions. These data support a planning paradigm in which redundancy is justified primarily by the low frequency but high impact of critical events, rather than by overall medical demand. Clinical Implications In large, seated stadium environments with controlled access and structured crowd flow, patient presentation rates may be lower than those predicted by generic mass-gathering risk stratification tools. A redundancy-based medical model integrated within a unified command–control framework appears capable of ensuring preparedness for rare high-acuity emergencies while minimizing unnecessary hospital transfers. These findings may inform context-specific medical planning strategies for large stadium-based sporting events. CONCLUSION Despite classification as moderate-to-high risk according to the Maurer algorithm, medical demand during international Six Nations matches at the Olympic Stadium was low and predominantly composed of minor presentations. The overall Patient Presentation Rate was limited, severe events were rare, and hospital transport was infrequent. The structured and redundancy-based medical deployment, combined with full integration within the Stadium Safety Operations Group and a unified command–control–communication framework, likely contributed to rapid on-site management, early interception of non-severe conditions, and minimal impact on regional emergency services. These findings suggest that, in large stadium-based sporting events with controlled access and seating, comprehensive on-site medical organisation can ensure high levels of safety while maintaining efficient use of healthcare resources. This model may inform medical planning strategies for similar mass-gathering events in comparable settings. Abbreviations ALS Advanced Life Support EMS Emergency Medical Services ER Emergency room HIA Head Injury Assessment PPR Patient Presentation Rate Declarations Ethics approval and consent to participate This retrospective observational study was conducted in accordance with national regulations governing retrospective analyses of anonymized operational data and did not involve any additional interventions or patient contact. Formal ethics committee approval and individual informed consent were not required according to current Italian regulations. All data were analyzed in anonymized form in compliance with the General Data Protection Regulation. The study was conducted in accordance with the principles of the Declaration of Helsinki. Consent for publication Not applicable. Availability of data and materials De-identified data underlying this article will be shared on reasonable request to the corresponding author, subject to institutional and regulatory constraints. Competing interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors' contributions AG and MC conceived the study. All authors collected and curated the data. AG and MC performed the statistical analyses. MC drafted the manuscript. All authors critically revised the manuscript for important intellectual content and approved the final version. Guarantor: AG accepts full responsibility for the work and the conduct of the study. Acknowledgements The authors thank the stadium medical staff and emergency response teams for their contribution to data collection and event medical coverage. We also acknowledge the Gemelli Medical Staff Group: Adduci Alessia, Barone Brigida, Bertolini Luca, Bisanti Alessandra, Brutti Alberto, Cascarano Laura, De Paulis Stefano, Del Tedesco Filippo, Dell’Anna Antonio Maria, Ferrara Laura, Galeotti Caterina, Galletta Claudia, Gennenzi Veronica, Iaculli Antonio, Malerba Giuseppe, Mancarella Francesco Antonio, Meloni Francesco, Montefrancesco Andrea, Natalini Daniele, Nicoletti Alberto, Piersanti Alessandra, Pisapia Luca, Portaccio Ivonne, Serravento Francesco, Sestito Luisa, Silvia Federico, Torelli Enrico, Tortorolo Luca, Tullo Gianluca, Valletta Federico, Zileri Dal Verme Lorenzo Patient and Public Involvement Patients and/or the public were not involved in the design, conduct, reporting, or dissemination plans of this research. Gemelli Medical Staff Group Adduci Alessia 1,4 , Barone Brigida 1,4 , Bertolini Luca 1,4 , Bisanti Alessandra 1,4 , Brutti Alberto 4 , Cascarano Laura 1,4 , De Paulis Stefano 4 , Del Tedesco Filippo 1,4 , Dell’Anna Antonio Maria 1,4 , Ferrara Laura 1,4 , Galeotti Caterina 1,4 , Galletta Claudia 1,4 , Gennenzi Veronica 1,4 , Iaculli Antonio 1,4 , Malerba Giuseppe 4 , Mancarella Francesco Antonio 4 , Meloni Francesco 1,4 , Montefrancesco Andrea 1,4 , Natalini Daniele 1,4 , Nicoletti Alberto 4 , Piersanti Alessandra 1,4 , Pisapia Luca 1,4 , Portaccio Ivonne 1,4 , Serravento Francesco 4 , Sestito Luisa 4 , Silvia Federico 1,4 , Torelli Enrico 4 , Tortorolo Luca 1,4 , Tullo Gianluca 1,4 , Valletta Federico 1,4 , Zileri Dal Verme Lorenzo 4 References Arbon P. Planning medical coverage for mass gatherings in Australia: what we currently know. J Emerg Nurs. 2008;34:346–50. Arbon P, Cusack L, Ranse J, et al. Evidence-based planning for mass-gathering health. 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Risk assessment and medical planning for mass gatherings. Notf Rettungsmed. 2010;13:195–202. Locoh-Donou S, Welcher M, Berry T, et al. Mass-gathering medicine: a descriptive analysis of a range of mass-gathering event types. Am J Emerg Med. 2016;34:1998–2003. Gibson J, O’Connor R, Walsh M. Medical care for spectators at large stadium events: experience from a European football stadium. Emerg Med J. 2016;33:249–54. Mercalli C, Ghio FE, Bonizzato S, et al. Providing medical care at mass gathering sporting events: the 2023 Ryder Cup experience. BMC Emerg Med. 2025;25:1316. Additional Declarations No competing interests reported. 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Polyclinic","correspondingAuthor":false,"prefix":"","firstName":"Kidane","middleName":"Wolde","lastName":"Sellasie","suffix":""},{"id":631489850,"identity":"b5e29183-c548-47b1-8dc7-b57783fdb1bf","order_by":6,"name":"Carla Caporale","email":"","orcid":"","institution":"Agostino Gemelli University Polyclinic","correspondingAuthor":false,"prefix":"","firstName":"Carla","middleName":"","lastName":"Caporale","suffix":""},{"id":631489861,"identity":"9c61a68f-2e9b-4b47-8258-f09be26ad213","order_by":7,"name":"Marcello Candelli","email":"","orcid":"","institution":"Agostino Gemelli University Polyclinic","correspondingAuthor":false,"prefix":"","firstName":"Marcello","middleName":"","lastName":"Candelli","suffix":""},{"id":631489862,"identity":"3aa73ac9-26f0-4e19-907b-e3d231ab46f8","order_by":8,"name":"Massimo Antonelli","email":"","orcid":"","institution":"Catholic University of the Sacred Heart","correspondingAuthor":false,"prefix":"","firstName":"Massimo","middleName":"","lastName":"Antonelli","suffix":""},{"id":631489863,"identity":"6f363c2f-e288-4411-af3f-a3471bb3bd5b","order_by":9,"name":"Gemelli Medical Staff Group","email":"","orcid":"","institution":"Agostino Gemelli University Polyclinic","correspondingAuthor":false,"prefix":"","firstName":"Gemelli","middleName":"Medical Staff","lastName":"Group","suffix":""}],"badges":[],"createdAt":"2026-04-01 09:43:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9289954/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9289954/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108398477,"identity":"c3440954-1eef-4a28-b38a-c29d87b550ac","added_by":"auto","created_at":"2026-05-04 08:31:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":584770,"visible":true,"origin":"","legend":"\u003cp\u003ePitch-side medical room\u003c/p\u003e\n\u003cp\u003eFully equipped emergency room dedicated to athlete care, including advanced life support monitoring, airway management devices, trauma equipment, point-of-care ultrasound, and mobile digital radiography.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9289954/v1/090e96cef38f84077bcafc2e.png"},{"id":108398478,"identity":"3bebcfc3-28c8-4078-9958-dc5115fbbf52","added_by":"auto","created_at":"2026-05-04 08:31:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":680803,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAmbulance disposition at the Olympic Stadium\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStrategic positioning of advanced life support ambulances inside and outside the venue to ensure rapid response capability. The ambulances in the upper right and lower left sectors were configured for biocontainment transport.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9289954/v1/1b4a2ceef84010f0162782c1.png"},{"id":108493078,"identity":"943f44a6-9c56-4836-ada3-ea54080c5a50","added_by":"auto","created_at":"2026-05-05 09:59:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1938801,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9289954/v1/8158f2f5-5c7a-494a-a349-8f6767621717.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Medical demand and emergency resource utilization during international rugby matches at a high-capacity stadium: a retrospective observational study","fulltext":[{"header":"KEY MESSAGE","content":"\u003cp\u003e\u003cstrong\u003eWhat is already known on this topic\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMass-gathering sporting events require structured medical planning yet reported patient presentation rates vary widely depending on event type, venue structure, and environmental factors. Detailed data from European rugby stadiums remain limited.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhat this study adds\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study provides comprehensive real-world data from seven international Six Nations matches, demonstrating a low patient presentation rate (3.6/10,000) and infrequent hospital transport despite moderate-to-high formal risk classification.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHow this study might affect research, practice or policy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThese findings suggest that highly structured stadium environments with integrated command systems may experience lower-than-anticipated medical demand, supporting refinement of risk stratification tools and resource allocation models for large sporting events.\u003c/p\u003e"},{"header":"BACKGROUND","content":"\u003cp\u003eMass-gathering sporting events pose unique challenges for medical planning, delivery, and coordination. International rugby competitions attract tens of thousands of spectators, often within stadiums of high capacity and complex logistical constraints, markedly different from dispersed events. Ensuring adequate medical preparedness is essential to minimise risks, provide timely care, and reduce unnecessary hospital transports. \u003csup\u003e1,4\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSpectator medicine has been described in various contexts, including football World Cups, Olympic Games, and more recently the Rugby World Cup 2019 in Japan, where most presentations were minor and strongly influenced by environmental, organizational and crowd-related factors. \u003csup\u003e4,7\u003c/sup\u003e However, published data for European rugby venues remain limited.\u003c/p\u003e \u003cp\u003eThe Six Nations Championship represents one of the most important annual rugby tournaments worldwide and provides an opportunity to evaluate a structured, risk-based, medical model in a high-capacity stadium. Rome hosts Italy\u0026rsquo;s home matches at the Olympic Stadium (Rome, Italy), a venue with a maximum capacity of approximately 70,000 spectators.\u003c/p\u003e \u003cp\u003eThis study provides the first comprehensive evaluation of spectator medical activity during seven Six Nations matches held between 2023 and 2025. Our objectives were to: describe the volume and type of medical presentations; assess severity distribution and hospital transport rates; and compare indicators with previously published international experiences.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eThis retrospective observational study analysed medical activity recorded during all international Six Nations rugby matches hosted at the Olympic Stadium between 2023 and 2025. The Olympic Stadium is a multi-purpose, all-seater stadium with controlled access and a maximum capacity of 69,689 spectators, excluding surrounding areas. Seven matches were held during the study period, and all eligible events were included; therefore, no formal sample size calculation was performed.\u003c/p\u003e \u003cp\u003eThe Six Nations is an annual international rugby union tournament held over five weekends between February and March, involving the national teams of England, France, Ireland, Italy, Scotland, and Wales. All Italian home matches are played at the Olympic Stadium. Across the seven matches included, mean ambient temperature was approximately 12\u0026deg;C, consistent with the winter\u0026ndash;early spring season. Rainfall occurred during four matches without thunderstorms, and weather conditions remained within predefined operational safety thresholds.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eMedical organization and emergency preparedness\u003c/h2\u003e \u003cp\u003eFor each match, a comprehensive on-site emergency medical service (EMS) was deployed to ensure advanced life support coverage for both spectators and players. Medical teams included physicians, anesthesiology\u0026ndash;intensive care specialists, nurses, trained first responders, and ambulance drivers. Medical resources comprised fixed medical posts, mobile response units, pitch-side ALS (Advanced Life Support) teams, and advanced life support ambulances positioned both inside and outside the stadium.\u003c/p\u003e \u003cp\u003eAthlete-specific emergency preparedness was ensured through dedicated pitch-side ALS teams and a fully equipped players\u0026rsquo; Emergency Room (ER) located within the athletes\u0026rsquo; area. The players\u0026rsquo; ER was staffed by ALS-trained physicians and nurses and equipped with advanced monitoring, resuscitation, airway management, trauma care devices, and diagnostic tools, including point-of-care ultrasound and mobile digital radiography (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A dedicated Head Injury Assessment (HIA) station with integrated video review and neurological testing facilities was also available.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRisk assessment and medical planning\u003c/h3\u003e\n\u003cp\u003eEvent risk assessment and healthcare planning were conducted in accordance with national guidelines for medical assistance at planned events and mass gatherings, as defined by the Italian State\u0026ndash;Regions Agreement of 5 August 2014 and its subsequent implementation decree \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Event risk was quantified using standardized scoring tables incorporating event-related and audience-related factors (Supplementary materials, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The cumulative score determined the overall event risk classification (Supplementary materials, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBased on the resulting risk classification, the type and number of medical and emergency resources required were defined using the Maurer algorithm, a structured mass-gathering risk stratification tool that translates event risk into predefined staffing levels and medical resource allocation. \u003csup\u003e9\u003c/sup\u003e Detailed scoring tables and regulatory references are provided in the Supplementary Material. All matches held during the study period were classified as moderate-to-high risk.\u003c/p\u003e\n\u003ch3\u003eMedical system organisation\u003c/h3\u003e\n\u003cp\u003e Spectator medical care was delivered through a structured, multi-layered network of medical posts fully integrated within the Stadium Safety Operations Group and operating under a unified command\u0026ndash;control\u0026ndash;communication framework. This organisation enabled real-time coordination between medical teams, stewards, safety officers, and the regional emergency medical service (Regional Emergency Medical Service, ARES 118), ensuring rapid identification, dispatch, and escalation of medical responses throughout the stadium.\u003c/p\u003e \u003cp\u003eIn addition to the central medical room and pitch-side advanced life support teams, the Olympic Stadium was equipped with an extensive spectator-oriented medical network designed to ensure rapid and redundant access to care across all seating areas and crowd densities. The in-stadium system included ten first-aid stations distributed across the main spectator sectors and four medical towers, ensuring comprehensive horizontal and vertical coverage of the venue. This configuration was specifically intended to reduce response times and facilitate care delivery in upper-tier seating areas, where evacuation times may be prolonged.\u003c/p\u003e \u003cp\u003eEach of the four medical towers was staffed with a dedicated ALS physician (anesthesiologist\u0026ndash;intensivist), providing immediate advanced life support capability at elevated seating levels. An additional ALS physician was assigned to the VIP and authorities\u0026rsquo; stand, ensuring dedicated advanced care coverage for high-profile seating areas.\u003c/p\u003e \u003cp\u003eThe ten first-aid stations were organised as dual-component units, consisting of a first responder team operating directly within the spectator stands and a medical team stationed in an adjacent medical room. This configuration allowed parallel management of on-site assessment and definitive care. All first-aid stations were staffed with physicians, nurses, and trained first responders. Two stations, located at opposite ends of the stadium, were further reinforced with an ALS physician to provide additional redundancy in geographically distant sectors. Each first-aid station and medical tower was equipped with essential emergency equipment, including oxygen supply, automated external defibrillators, immobilisation devices, and basic trauma and medical supplies.\u003c/p\u003e \u003cp\u003eTo extend medical coverage beyond the stadium perimeter, two external first-aid posts were established in the main ingress and egress areas. Each external unit consisted of a medical tent equipped with two treatment beds, a dedicated ambulance, and a medical team including an ALS physician, a nurse, and an ambulance driver. These posts managed medical presentations occurring during pre-event access, post-match crowd dispersal, and within designated post-event social areas (\u0026ldquo;third half\u0026rdquo;), where alcohol consumption and minor trauma are more frequent.\u003c/p\u003e \u003cp\u003eThe integration of internal and external medical posts within the GOS structure facilitated early interception and treatment of non-severe conditions, efficient escalation of critical cases, and optimisation of medical resource utilisation, while maintaining continuous situational awareness and immediate ALS availability across the venue.\u003c/p\u003e\n\u003ch3\u003eData collection and documentation\u003c/h3\u003e\n\u003cp\u003eAll medical teams were equipped with standardized paper-based medical encounter forms used for real-time documentation during each intervention. For every medical presentation, personnel systematically recorded the date and time of the event, stadium sector or location, primary symptoms or reason for presentation, assigned triage severity code (white, green, yellow, or red), vital signs when clinically indicated, administered treatments, and outcome of the medical encounter (on-site resolution, hospital transport, or refusal of transport). Paper forms were completed contemporaneously at the point of care and subsequently reviewed and entered a dedicated anonymized database for retrospective analysis. This standardized documentation process ensured consistency across all medical posts, mobile units, and pitch-side teams, allowing reliable aggregation of clinical and operational data across matches. All medical encounter forms were complete for the variables analysed, and no missing data were identified. This study analyzed routinely collected anonymized data from all spectators requiring medical attention during the study period. No exclusions were made based on sex, gender, ethnicity, socioeconomic status, disability, or other protected characteristics. The study team included clinicians with expertise in emergency medicine and mass-gathering medical planning. Given the retrospective design, no direct patient or public involvement was feasible. According to national regulations, formal ethics committee approval and individual informed consent were not required for retrospective analyses of anonymized service data.\u003c/p\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003ePatient presentation and hospital transport rates were calculated per 10,000 individuals present at the venue, in line with commonly used metrics in mass-gathering medicine. \u003csup\u003e10\u003c/sup\u003e The population at risk included spectators, school groups, and accredited staff physically present at the stadium.\u003c/p\u003e \u003cp\u003eSecondary outcomes included triage severity distribution, hospital transport rate per 10,000 attendees, refusal of transport, and descriptive reporting of medical resource deployment.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics were used to summarise medical encounters, triage severity, and resource utilisation. Continuous variables are reported as means with standard deviations, as appropriate. Categorical variables are presented as counts and percentages. Patient presentation and hospital transport rates were calculated per 10,000 individuals present at the venue with 95% confidence intervals calculated using exact Poisson methods.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eAttendance and population at risk\u003c/h2\u003e \u003cp\u003eSeven international Six Nations rugby matches were included in the analysis.\u003c/p\u003e \u003cp\u003eAcross these events, the total number of individuals physically present at the venue, including spectators, school groups, and accredited staff, amounted to 451,934. This number was used as the population at risk for all subsequent analyses, as all categories were potentially exposed to on-site medical services.\u003c/p\u003e \u003cp\u003eEvent risk assessment classified the event as moderate-to-high risk. Accordingly, and in line with the Maurer algorithm, a structured medical and emergency response plan was implemented. The deployed resources included a dedicated Medical Service Director (anesthesiologist/intensivist), a resources and logistics coordinator, 10 physicians with an additional physician assigned to the third-half area, and 12 anesthesiology and critical care physicians distributed across the field of play, athlete-dedicated areas, and third-half facilities. The healthcare team further comprised 38 nurses, 38 first responders, and 14 ambulance drivers. Advanced life support coverage was ensured by 12 ALS units strategically positioned inside and outside the venue, complemented by two on-field electric medical micro-cars. Additional support included two sanitization teams and two coordination units to ensure operational continuity throughout the event.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarises the medical and emergency resources deployed per match, both overall and normalized per 10,000 spectators.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMedical and emergency resources deployed per event and per 10,000 spectators\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResource\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeployed per event\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePer 10,000 spectators*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical Service Director (Anesthesiology/ICU)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLogistics and resources coordinator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysicians, total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ndash; Anesthesiology / Critical care physicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ndash; Other physicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst responders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmbulance drivers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdvanced Life Support units\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOn-field medical micro-cars\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFixed medical posts / towers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExternal first-aid posts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSanitization teams\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Per 10,000 spectators, assuming an average attendance of approximately 65,000 spectators per match. Figure\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the disposition of the ambulances at the Stadium.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eMedical encounters and triage severity\u003c/h2\u003e \u003cp\u003eDuring the study period, a total of 162 medical encounters were recorded, corresponding to a mean of 23 (\u0026plusmn;\u0026thinsp;6.4 SD) interventions per match. Triage severity codes were predominantly of low acuity, with 86 white-code cases (53.1%) and 60 green-code cases (37.0%), while higher-acuity presentations were less frequent, including 13 yellow-code cases (8.0%) and 3 red-code cases (1.9%). Among the 162 medical encounters recorded across the included matches, 12 patients (7.4%) required hospital transportation and admission. In addition, 14 patients (8.6%) refused hospital transfer after on-site medical assessment and clinical stabilisation. The remaining cases were managed entirely on site without the need for hospital referral.\u003c/p\u003e \u003cp\u003eThe Patient Presentation Rate (PPR) was calculated as the number of medical presentations per 10,000 attendees, using the total number of individuals physically present at the venue\u0026mdash;including spectators, school groups, and accredited staff\u0026mdash;as the denominator (n\u0026thinsp;=\u0026thinsp;451,934). Overall, the PPR was 3.6 per 10,000 attendees (95% CI 3.1 to 4.2). Severity-specific PPRs were 1.9 per 10,000 (95% CI 1.5 to 2.4) for white-code presentations, 1.3 per 10,000 (95% CI 1.0 to 1.7) for green-code presentations, 0.3 per 10,000 (95% CI 0.15 to 0.49) for yellow-code presentations, and 0.1 per 10,000 (95% CI 0.01 to 0.19) for red-code presentations. The hospital transport rate was 0.27 per 10,000 attendees (95% CI 0.14 to 0.46). Low-acuity presentations therefore accounted for most medical encounters, while high-acuity events were rare.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMatch-level spectator medical activity and Patient Presentation Rate (PPR)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMatch date\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAttendance\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhite code\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGreen code\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYellow code\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRed code\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTotal encounters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePPR\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8/2/2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e23/2/2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e68276\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15/3/2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e71981\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3/2/2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9/3/2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e72189\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25/2/2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53234\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11/3/2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63736\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e451934\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e64562\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e23.1\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eType of medical presentations\u003c/h2\u003e \u003cp\u003eMedical presentations were predominantly related to trauma, which accounted for 64 cases (39.5%). Cardiovascular complaints were the second most frequent cause (23 cases, 14.2%), followed by neurological symptoms (11 cases, 6.8%). Gastrointestinal disorders (9 cases, 5.6%), alcohol-related presentations (10 cases, 6.2%), and allergic reactions (7 cases, 4.3%) were less common. Respiratory complaints (2 cases, 1.2%) and glycaemic disturbances (1 case, 0.6%) were rare. No isolated panic attacks were recorded. In addition, 35 presentations (21.6%) involved mixed or non-specific symptoms requiring combined clinical assessment. Of the 162 medical encounters recorded, 30 (18.5%) concerned accredited staff members. Overall, most medical encounters were related to minor trauma or transient medical conditions.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study provides a comprehensive evaluation of spectator medical activity during international Six Nations rugby matches held at a large European stadium, formally classified as moderate-to-high risk according to the Maurer algorithm. Despite a formal moderate-to-high risk classification, the observed medical workload corresponded to fewer than four medical encounters per 10,000 attendees and fewer than one hospital transport per 30,000 attendees.\u003c/p\u003e \u003cp\u003eThese results suggest a potential discrepancy between the anticipated risk level derived from standardized mass-gathering risk stratification tools and the actual medical demand observed during international rugby matches held in a highly structured stadium environment. In line with this observation, previous reports from large European stadium events have similarly described a predominantly low medical workload, largely composed of minor conditions, despite substantial levels of medical preparedness.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSimilar patterns of low clinical workload despite high levels of preparedness have been reported during other large sporting events, including the Rugby World Cup 2019 and the Ryder Cup 2023\u003csup\u003e12\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe observed PPR is consistent with, or slightly higher than, values reported during other international rugby events, such as the Rugby World Cup 2019 in Japan (2.63/10,000), and markedly lower than those reported for other mass-gathering sporting events characterised by prolonged exposure, outdoor mobility, and environmental stressors, such as the Ryder Cup 2023 (16.5/10,000). These comparisons highlight the influence of event typology and venue structure on medical demand. \u003csup\u003e6, 12\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eNotably, most medical presentations were of low acuity, with white- and green-code cases accounting for more than 90% of encounters, and fewer than 8% of cases requiring hospital transport. This pattern suggests that, in highly structured stadium environments with controlled access, seating, and crowd movement, generic mass-gathering risk stratification tools may conservatively overestimate the expected clinical workload, while still appropriately identifying the potential for high-consequence events.\u003c/p\u003e \u003cp\u003eImportantly, despite the overall low medical workload, the deployed medical system proved capable of managing rare but high-acuity emergencies. During the study period, red-coded events included an out-of-hospital cardiac arrest with successful resuscitation and favourable neurological outcome, an acute myocardial infarction, and a ruptured abdominal aortic aneurysm, all managed on site with prompt advanced care and associated with good clinical outcomes.\u003c/p\u003e \u003cp\u003eThe low incidence of severe medical events observed in this study likely reflects both contextual and organisational factors. From an environmental perspective, the winter\u0026ndash;early spring timing of the Six Nations may have reduced heat-related illness and dehydration. From an organisational standpoint, the extensive, redundancy-based medical deployment\u0026mdash;including widespread first-aid stations, medical towers with on-site anaesthesiologist\u0026ndash;intensivists, pitch-side ALS teams, mobile response units, and a fully equipped players\u0026rsquo; Emergency Room\u0026mdash;enabled rapid assessment, early treatment, and efficient triage of medical presentations.\u003c/p\u003e \u003cp\u003eImportantly, the integration of all medical resources within the Stadium Safety Operations Group and a unified command\u0026ndash;control\u0026ndash;communication framework ensured real-time situational awareness and coordinated response across the venue. This integrated approach likely contributed to early interception of non-severe conditions, minimised secondary crowd movement, and reduced unnecessary escalation to hospital-based emergency services.\u003c/p\u003e \u003cp\u003eTaken together, these findings support the potential value of a structured, redundancy-oriented medical model for large stadium-based sporting events. While resource-intensive, such an approach appears to ensure both safety and system resilience, allowing rapid response to critical incidents while maintaining efficient management of the large volume of minor presentations typically encountered in spectator medicine.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations that should be acknowledged. First, its retrospective observational design relies on routinely collected medical data, which may be subject to incomplete documentation or reporting variability despite the use of standardized paper-based medical forms and structured triage protocols. However, the uniform documentation framework applied across all medical posts and mobile teams was intended to minimize heterogeneity in data collection.\u003c/p\u003e \u003cp\u003eSecond, the analysis was conducted at a single venue, the Olympic Stadium in Rome, and reflects the organizational model, crowd characteristics, and environmental conditions specific to this setting. While the findings are likely generalizable to other large European rugby stadiums, caution is warranted when extrapolating results to different sports, venues, or healthcare systems.\u003c/p\u003e \u003cp\u003eThird, follow-up data were not available for patients transported to hospital or for those who refused transport. As a result, downstream clinical outcomes could not be assessed, and the study focuses exclusively on on-site medical activity and immediate disposition.\u003c/p\u003e \u003cp\u003eFinally, although all matches were classified as moderate-to-high risk according to the Maurer algorithm, medical demand was influenced by contextual factors such as winter\u0026ndash;early spring climate and controlled stadium access, which may have contributed to the low incidence of heat-related illness and severe presentations. These factors should be considered when comparing patient presentation rates with events held in different environmental or seasonal conditions.\u003c/p\u003e \u003cp\u003eThese data support a planning paradigm in which redundancy is justified primarily by the low frequency but high impact of critical events, rather than by overall medical demand.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eClinical Implications\u003c/h2\u003e \u003cp\u003eIn large, seated stadium environments with controlled access and structured crowd flow, patient presentation rates may be lower than those predicted by generic mass-gathering risk stratification tools. A redundancy-based medical model integrated within a unified command\u0026ndash;control framework appears capable of ensuring preparedness for rare high-acuity emergencies while minimizing unnecessary hospital transfers. These findings may inform context-specific medical planning strategies for large stadium-based sporting events.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eDespite classification as moderate-to-high risk according to the Maurer algorithm, medical demand during international Six Nations matches at the Olympic Stadium was low and predominantly composed of minor presentations. The overall Patient Presentation Rate was limited, severe events were rare, and hospital transport was infrequent.\u003c/p\u003e \u003cp\u003eThe structured and redundancy-based medical deployment, combined with full integration within the Stadium Safety Operations Group and a unified command\u0026ndash;control\u0026ndash;communication framework, likely contributed to rapid on-site management, early interception of non-severe conditions, and minimal impact on regional emergency services.\u003c/p\u003e \u003cp\u003eThese findings suggest that, in large stadium-based sporting events with controlled access and seating, comprehensive on-site medical organisation can ensure high levels of safety while maintaining efficient use of healthcare resources. This model may inform medical planning strategies for similar mass-gathering events in comparable settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eALS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdvanced Life Support\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEMS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEmergency Medical Services\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eER\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEmergency room\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHIA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHead Injury Assessment\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePPR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePatient Presentation Rate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective observational study\u0026nbsp;was conducted in accordance with national regulations governing retrospective analyses of anonymized operational data\u0026nbsp;and did not involve any additional interventions or patient contact. Formal ethics committee approval and individual informed consent were not required according to current Italian regulations. All data were analyzed in anonymized form in compliance with the\u0026nbsp;General Data Protection Regulation. The study was conducted in accordance with the principles of the\u0026nbsp;Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDe-identified data underlying this article will be shared on reasonable request to the corresponding author, subject to institutional and regulatory constraints.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAG and MC conceived the study. All authors collected and curated the data. AG and MC performed the statistical analyses. MC drafted the manuscript. All authors critically revised the manuscript for important intellectual content and approved the final version.\u003cbr\u003e\u003cstrong\u003eGuarantor:\u003c/strong\u003e AG accepts full responsibility for the work and the conduct of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the stadium medical staff and emergency response teams for their contribution to data collection and event medical coverage. We also acknowledge the Gemelli Medical Staff Group: Adduci Alessia, Barone Brigida, Bertolini Luca, Bisanti Alessandra, Brutti Alberto, Cascarano Laura, De Paulis Stefano, Del Tedesco Filippo, Dell\u0026rsquo;Anna Antonio Maria, Ferrara Laura, Galeotti Caterina, Galletta Claudia, Gennenzi Veronica, Iaculli Antonio, Malerba Giuseppe, Mancarella Francesco Antonio, Meloni Francesco, Montefrancesco Andrea, Natalini Daniele, Nicoletti Alberto, Piersanti Alessandra, Pisapia Luca, Portaccio Ivonne, Serravento Francesco, Sestito Luisa, Silvia Federico, Torelli Enrico, Tortorolo Luca, Tullo Gianluca, Valletta Federico, Zileri Dal Verme Lorenzo\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePatient and Public Involvement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients and/or the public were not involved in the design, conduct, reporting, or dissemination plans of this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGemelli Medical Staff Group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdduci Alessia\u003csup\u003e1,4\u003c/sup\u003e, Barone Brigida\u003csup\u003e1,4\u003c/sup\u003e, Bertolini Luca\u003csup\u003e1,4\u003c/sup\u003e, Bisanti Alessandra\u003csup\u003e1,4\u003c/sup\u003e, Brutti Alberto\u003csup\u003e4\u003c/sup\u003e, Cascarano Laura\u003csup\u003e1,4\u003c/sup\u003e, De Paulis Stefano\u003csup\u003e4\u003c/sup\u003e, Del Tedesco Filippo\u003csup\u003e1,4\u003c/sup\u003e, Dell\u0026rsquo;Anna Antonio Maria\u003csup\u003e1,4\u003c/sup\u003e, Ferrara Laura\u003csup\u003e1,4\u003c/sup\u003e, Galeotti Caterina\u003csup\u003e1,4\u003c/sup\u003e, Galletta Claudia\u003csup\u003e1,4\u003c/sup\u003e, Gennenzi Veronica\u003csup\u003e1,4\u003c/sup\u003e, Iaculli Antonio\u003csup\u003e1,4\u003c/sup\u003e, Malerba Giuseppe\u003csup\u003e4\u003c/sup\u003e, Mancarella Francesco Antonio\u003csup\u003e4\u003c/sup\u003e, Meloni Francesco\u003csup\u003e1,4\u003c/sup\u003e, Montefrancesco Andrea\u003csup\u003e1,4\u003c/sup\u003e, Natalini Daniele\u003csup\u003e1,4\u003c/sup\u003e, Nicoletti Alberto\u003csup\u003e4\u003c/sup\u003e, Piersanti Alessandra\u003csup\u003e1,4\u003c/sup\u003e, Pisapia Luca\u003csup\u003e1,4\u003c/sup\u003e, Portaccio Ivonne\u003csup\u003e1,4\u003c/sup\u003e, Serravento Francesco\u003csup\u003e4\u003c/sup\u003e, Sestito Luisa\u003csup\u003e4\u003c/sup\u003e, Silvia Federico\u003csup\u003e1,4\u003c/sup\u003e, Torelli Enrico\u003csup\u003e4\u003c/sup\u003e, Tortorolo Luca\u003csup\u003e1,4\u003c/sup\u003e, Tullo Gianluca\u003csup\u003e1,4\u003c/sup\u003e, Valletta Federico\u003csup\u003e1,4\u003c/sup\u003e, Zileri Dal Verme Lorenzo\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eArbon P. Planning medical coverage for mass gatherings in Australia: what we currently know. J Emerg Nurs. 2008;34:346\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArbon P, Cusack L, Ranse J, et al. Evidence-based planning for mass-gathering health. Prehosp Disaster Med. 2013;28:231\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Lorenzo RA. Mass gathering medicine: a review. Prehosp Disaster Med. 1997;12:68\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMilsten AM, Maguire BJ, Bissell RA, et al. Mass-gathering medical care: a review of the literature. Prehosp Disaster Med. 2002;17:151\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Public health for mass gatherings: key considerations. Geneva: WHO; 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamamoto T. Medical care at the Rugby World Cup 2019 in Japan: spectator and team medical services. Br J Sports Med. 2021;55:35\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMemish ZA, Steffen R, White P, et al. Mass gatherings medicine: public health issues arising from mass gathering religious and sporting events. Lancet Infect Dis. 2019;19:e1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eItalian Ministry of Health. State\u0026ndash;Regions Agreement on guidelines for the organization of health services at planned events and mass gatherings (Rep. Atti No. 91, 5 August 2014), implemented by Commissioner\u0026rsquo;s Decree No. U00466 of 7 November 2017. Rome: Ministry of Health; 2014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaurer E. Risk assessment and medical planning for mass gatherings. Notf Rettungsmed. 2010;13:195\u0026ndash;202.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLocoh-Donou S, Welcher M, Berry T, et al. Mass-gathering medicine: a descriptive analysis of a range of mass-gathering event types. Am J Emerg Med. 2016;34:1998\u0026ndash;2003.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGibson J, O\u0026rsquo;Connor R, Walsh M. Medical care for spectators at large stadium events: experience from a European football stadium. Emerg Med J. 2016;33:249\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMercalli C, Ghio FE, Bonizzato S, et al. Providing medical care at mass gathering sporting events: the 2023 Ryder Cup experience. BMC Emerg Med. 2025;25:1316.\u003c/span\u003e\u003c/li\u003e "}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Mass gatherings, Emergency medical services, Rugby, Stadium medicine, Patient presentation rate, Sports medicine","lastPublishedDoi":"10.21203/rs.3.rs-9289954/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9289954/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTo describe medical activity, emergency resource deployment, and patient outcomes during international rugby matches held at a high-capacity stadium.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective observational study of all medical encounters recorded during seven international rugby matches held at the Olympic Stadium (Rome, Italy) between 2023 and 2025. Event risk assessment and medical planning were performed using a standardized mass-gathering risk stratification approach. Patient Presentation Rate (PPR) and hospital transport rate were calculated per 10,000 attendees.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAcross the seven matches, 451,934 individuals were present at the venue. A total of 162 medical encounters were recorded, corresponding to a PPR of 3.6 per 10,000 attendees. Most presentations were of low acuity, with 86 white-code (53.1%) and 60 green-code (37.0%) cases. Higher-acuity events were uncommon (13 yellow-code [8.0%] and 3 red-code [1.9%]). Twelve patients (0.3 per 10,000) required hospital transport, while 14 refused transfer after on-site assessment. Medical deployment included physicians, anaesthesiology\u0026ndash;intensive care specialists, nurses, first responders, advanced life support units, and mobile response teams, ensuring comprehensive on-site coverage.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eDespite formal classification as moderate-to-high risk, medical demand during international rugby matches was low and predominantly consisted of minor presentations. Extensive on-site EMS deployment enabled effective management of medical events and minimised hospital transport. These findings support the potential value of structured, redundancy-based medical models for large stadium-based sporting events.\u003c/p\u003e","manuscriptTitle":"Medical demand and emergency resource utilization during international rugby matches at a high-capacity stadium: a retrospective observational study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-04 08:31:43","doi":"10.21203/rs.3.rs-9289954/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-13T01:47:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"31536473567424622625822337543938474919","date":"2026-05-07T08:43:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-03T21:45:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"165922658807847045662048167812006121119","date":"2026-05-02T11:22:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-28T10:02:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"295815601861076307367036826107501859231","date":"2026-04-24T09:16:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"96409962637766609180211438774014396865","date":"2026-04-23T12:44:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"136652331750867485464435877428484324917","date":"2026-04-22T08:47:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-22T06:22:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"132448716813006975278607513902312250374","date":"2026-04-22T03:40:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-21T21:07:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-20T17:20:16+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-10T06:33:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-09T08:43:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Emergency Medicine","date":"2026-04-09T07:59:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2a4b3f6a-d624-47c7-b79a-afe96dbade95","owner":[],"postedDate":"May 4th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-13T01:47:40+00:00","index":61,"fulltext":""},{"type":"reviewerAgreed","content":"31536473567424622625822337543938474919","date":"2026-05-07T08:43:53+00:00","index":60,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-03T21:45:52+00:00","index":57,"fulltext":""},{"type":"reviewerAgreed","content":"165922658807847045662048167812006121119","date":"2026-05-02T11:22:05+00:00","index":56,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T08:31:43+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-04 08:31:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9289954","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9289954","identity":"rs-9289954","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}