Using Risk Assessment to Determine First Aid Requirements for Adventure Activities and Events A document for discussion November 2013
Contents Purpose....................................................................................................................................... 2 Background ................................................................................................................................ 2 Range of conditions................................................................................................................... 4 1) Pre-existing medical conditions unrelated to the event that may be exacerbated by the event......................................................................................................................................... 4 2)
Minor injuries or event-specific conditions......................................................................... 4
3)
Event-specific presentations. ............................................................................................ 5
Guideline 1: Planning ................................................................................................................ 7 Event rating as a basis for planning level of medical response to be provided......................... 7 Risk management as a tool for planning medical resources................................................. 7 Event ........................................................................................................................................ 7 Venue ....................................................................................................................................... 7 Crowd ....................................................................................................................................... 8 Weather.................................................................................................................................... 8 Timings..................................................................................................................................... 8 Communications....................................................................................................................... 8 Transport .................................................................................................................................. 9 Operational plan and coordination............................................................................................ 9 Guideline 2: Medical resources and qualifications............................................................... 10 Ensuring the right number of first aid personnel ..................................................................... 10 Ensuring appropriate competency and duties ........................................................................ 10 Major incidents ....................................................................................................................... 12 First aid posts ......................................................................................................................... 12 Medical equipment ................................................................................................................. 13 Guideline 3: Reporting............................................................................................................. 14 Medical Services Providers .................................................................................................... 16 First Aid Providers .................................................................................................................. 16 Ambulance Services............................................................................................................... 16
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Introduction Purpose This discussion paper has been prepared to facilitate discussion on health and first aid requirements for adventure type outdoor events to enable supplemental guidelines to the current events guidelines to be developed.
Background Western Australia (WA) is unique in its size and geographical isolation. This makes it especially important to ensure that adequate plans are put in place to cater for any medical emergencies that may occur at any pre-planned event, particularly those which have an anticipated number of attendees that is larger than the normal daily population at that location. Risk management is a key component to determine the resources necessary to manage any casualties. The goal is to reduce the severity of any injuries that do occur. The Department of Health (DOH) resources available for care of the critically unwell are severely limited outside the metropolitan area. Whilst the Royal Flying Doctor Service and St John Ambulance WA provide an excellent transfer service to Perth hospitals for anyone who is seriously injured or unwell, neither provider has any capability to transfer large numbers of persons at any one time. In addition, if health resources are overwhelmed in the metropolitan area, then the expected time for assistance to arrive from interstate is approximately 24–36 hours. The Parliamentary Enquiry into the Racing the Planet tragedy recommendation 11 requires organisers of eligible events to provide medical and risk management plans to relevant authorities for assessment – prior to any event approval being completed and the Coronial Inquiry into the Big Day Out music festival Jemma Thoms death in 2009 identified that appropriate levels of first aid was a critical issue. These factors make it vitally important that appropriate risk management planning is carried out at the planning stage to ensure that measures for managing medical emergencies and first aid care are in place.
Aims of this document 1. To reinforce the requirement for event organisations to have a culture of risk management using the process outlined in the Standard AS/NZS ISO 31000:2009. 2. To ensure that event organisers understand the appropriate level of medical and first aid care to be available for participants, officials, and spectators attending the event. 3. To reduce the severity of an incident and achieve the best possible medical outcome.
The background of risk management •
Risk management is a logical and systematic method to identify, analyse, treat, monitor and communicate risks associated with any activity, function or process.
•
Effective risk management is essential for the success of any public event.
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•
Risk management plans should be developed in accordance with AS/NZS ISO 31000:2009 - Risk Management.
•
Liquor Licensing, Local government and other agencies have discretion to require plans for events. The event manager is responsible for preparing the plans which must be submitted to the local government for approval.
•
Plans should be owned by the event manager and treated as confidential by other stakeholders.
Risk management AS/NZS ISO 31000:2009 AS/NZS ISO 31000:2009 is a generic guide to establish and implement a risk management plan. It outlines steps which, when taken in sequence, will enable continual improvement in decision making. IS ABOUT
IS NOT ABOUT
Ensuring Safety
Creating a totally risk free society
Balancing benefits and risks, with a focus on reducing real risks
Generating useless piles of paperwork
Enabling innovation and learning
Scaring people by exaggerating or publicising trivial risks
Ensuring that those who create risks manage them responsibly
Stopping important recreational and learning activities where the risks are managed
Ensuring individuals understand that as well as the right to protection, they also have responsibilities
Reducing protection of people from risks that cause real harm and suffering
Responsibilities of event organisers Event organisers are responsible for ensuring that:•
Risk management in accordance with AS/NZS ISO 31000:2009 Risk Management standard is applied to identify and quantify risks.
•
Risk management plans should include medical and first aid considerations, communications, and traffic management, to ensure all stakeholders have a shared understanding of how event emergencies will be managed.
•
First aid and ambulance service providers are competent and sufficient resources to address the credible risks
Event organisers’ reputations are dependent upon the pre event planning with all key stakeholders, rescue and medical providers. Event organisers must understand and be fully satisfied that all stakeholders have a shared understanding of how event emergencies will be managed and the level of care that can be provided by first aid and ambulance services. Planning must include traffic management specifically around access to casualties and egress for ambulances and other emergency services both within and external to the site.
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On-site ambulances are required where life threatening or serious emergencies are likely and attendance by an offsite ambulance would normally exceed 10 minutes, or where a regional ambulance may need to attend an emergency and leave the district.
Responsibilities of first aid providers First aid providers need to be fully conversant with event risks and courses and not presume that the event site will be the same as on previous occasions. Medical plans should be developed utilising historical data of similar events and the risks identified utilising the process outlined in AS/NZS ISO 31000:2009. Health risks identified in the Risk Management process must also be incorporated into the Event Risk Management Plan. The number of first aid personnel and first aid posts will vary with the type of event. First aid posts must be conspicuous, well lit at night and located at appropriate locations that are accessible to ambulance transport.
Range of conditions Table 1 gives a comprehensive view of event types, and what injuries one might expect to encounter at these events. Experience from different types of events shows that patient presentations are within three (3) main groups: 1) Pre-existing medical conditions unrelated to the event that may be exacerbated by the event. For example: •
heart disease
•
epilepsy
•
mental health crisis
•
diabetes
Some of these may be serious, and over an extended period of time there is potential for deaths to occur. Appropriately trained and experienced personnel are required to recognise and adequately treat or transport these patients. 34 2) Minor injuries or event-specific conditions. For example: •
sunburn
•
blisters
•
minor cuts and abrasions
•
dehydration
•
heat exhaustion
•
soft tissue injuries
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These usually make up the bulk of medical presentations and most can be dealt with by first aid level personnel. However, some may deteriorate and re-present with worsening problems, or may not respond to simple first aid measures. Qualified medical or paramedical personnel may be required to assess and treat these patients and some may be referred to an Emergency Department, or to their GP. Some may require transport to hospital. 3) Event-specific presentations. Examples of typical injuries at WA events. •
trips and falls
•
fractures
•
burns
•
high-impact or high-risk sports injuries
•
vehicle related trauma (motorsport).
Some patients will need a high level of care and pain relief and may require urgent medical attention and evacuation to a tertiary hospital. NOTE: There are no tertiary hospitals in regional areas.
Please provide comment on:1. Are the sections outlining responsibilities complete and sufficient? 2. Does Table 1 (on the following page) cover all types of events that occur in WA, and their corresponding injuries? 3. What clinical intervention is permitted under your sport/activity rules in relation to injury or rehydration
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Concert
Cycling
Dirt Bikes
Equestrian
Harness Racing
Kayaking
Motocross
Motor Racing / Cycling
Motoring
Motorsport
Polocrosse
Race
Rodeo
Speedway
Sport
Surfing
Swimming
Thoroughbred Races
Trail Running
Triathlon
Ultra Race
Yachting
Drag Races
Distance Run
Extract patient from difficult location
Substance / Drugs
Alcohol
Hypothermia Hyperthermia
Camp Draft
Dehydration
Drowning
Eye Injuries
Boating
Burns
Soft Tissue
Spinal/neck injury
Cardiac
Fracture/dislocation
Respiratory
Cuts abrasions
Adventure Race
Allergy
Injuries
Table 1: Event Injury Profiles
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Guideline 1: Planning Event rating as a basis for planning level of medical response to be provided The Event Injury Profile Table, Table 1, attempts to identify types of events and typical injuries that are likely to present at each type of event. Planning should consider both singular events, where a patron or competitor of the event is injured and also mass casualties, where a number of casualties may overwhelm the event and local health resources. An important consideration is the time for casualties to reach primary or tertiary treatment, particularly for events held in regional or remote locations.
Risk management as a tool for planning medical resources The following issues are included to assist with identifying hazards that may be applicable: Event •
Identify any hazards associated with the event or primary purpose by using a risk management process in accordance with AS NZS 31000.
•
It is not proposed to address specific requirements of the Risk Management standard. For the purposes of the workshop it is assumed that participants have a basic knowledge of the principles required by the standard.
•
The process should identify inherent dangers to participants, officials, staff or spectators.
•
Identify any dangers caused by crowd interaction with participants or other segments of the crowd.
•
Identify if there are any other concurrent events that may cause delays to emergency responders or unduly interrupt event access both before and after the event.
Venue •
Are there any environmental hazards within the venue or near vicinity?
•
Does the location cause any delays with regards to transport of staff or the injured?
•
Does the event disrupt the neighbouring community and their access to emergency responders?
•
Are there multiple areas of interest or crowd segments that should be staffed separately?
•
Is the event a regular occurrence at this site?
•
What services/utilities are available on site?
•
What temporary services/utilities are required?
•
Are backup resources required?
•
Are there existing designated emergency evacuation routes or do these need to be established and maintained?
•
Are there any dangers associated with these routes?
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•
Is there parking for those vehicles (And turning space)?
•
What is the topography of the venue? Is off road transport required? Additional risks?
•
What staffing issue does this raise?
Crowd •
What numbers are expected (and when)?
•
What age range are the crowd expected to be? What problems can this cause (elderly – medical conditions, young – fighting)?
•
Is the nature of the entertainment likely to cause the crowd to crush?
•
Are there likely to be mobility impaired persons there?
•
Are the crowd likely to be drinking or using drugs?
•
Are any of the crowd likely to be carrying weapons?
•
What is the ethnic composition of the crowd?
•
Are cultural issues involved or interpreters needed?
•
Can any of these problems or resulting dangers be prevented?
Weather •
What type of weather is it likely to be - before, during and after the event?
•
What effects can the weather have on the crowd, entertainment and your staff?
•
What effect can the weather have on resources, transport and communication?
Timings •
What time is the event being held?
•
How long does it last for?
•
Will staff require shifts, rest periods, meals etc?
Command control and coordination Communications •
What communications are there between essential stakeholders?
•
Have the communications been tested? And do they have redundancy e.g. mobile phones will be overloaded so need radios/satellite phones.
•
How does request or support with regard to patient transfer or other requirements occur?
•
How will batteries be recharged?
•
What call signs/frequencies etc have been allocated? Key contact list (phones, radios).
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•
Will communications interfere with the event broadcast systems?
•
Does the local Ambulance Operations Centre know of your key locations? Have they been contacted and made aware of the event?
•
Is there a command/coordination centre for services on site?
•
Are local support services such as hospitals aware of this event?
•
How will hospitals be notified if they are required to respond? Hospitals will only respond to a mass casualty event – activation by SHICC.
Transport •
How will patients be transported to First aid centres on site? E.g. Use of golf buggies?
•
How will patient transfers to hospital or other places be arranged?
•
How will staff get around the site?
•
What routes should routine/emergency transport follow? Identified access and egress routes that are monitored to ensure they remain clear throughout the event.
•
4WD ambulance capabilities in WA.
•
Has the time to transport to hospital been calculated – tertiary hospital in metro area only.
•
Does the RFDS need to be notified of the event?
Operational plan and coordination •
Has a copy of the operational plan been provided and included in the Risk Management Plan?
•
Have the medical/first aid providers been invited to attend the pre-event planning and briefings?
•
Have regular briefings throughout the event been organised?
Please provide comment on:1.
Do you consult with any other documents (other than the WA Event Guidelines) when planning first aid resources at your events, e.g. from other states, or even overseas (such as the NSW Event Starter Guide or the UK Purple or Green Guides)
2.
Does Guideline 1 adequately cover relevant issues when it comes to considering what level of first aid resources you will require at your events?
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Guideline 2: Medical resources and qualifications Ensuring the right number of first aid personnel The number and competence of medical personnel and first aid facilities will vary with the type of event. A risk assessment should determine the required resources and these requirements should be compared with other available information compiled from previous similar events. Utilise recommendations from existing guides.
Ensuring appropriate competency and duties All medical personnel should have appropriate professional indemnity insurance, hold current relevant qualifications from an accredited training provider complying with the Australian Qualifications Training Framework (AQTF) and practice within the scope of the level at which they are trained. The AQTF table on the following page identifies the skill sets required to address the identified casualties to assist with determining the level of medical resources and planning required for an event. The key component of this assessment is how well casualties can be managed, pain relief and ongoing medical treatment until the casualty is admitted to an appropriate level of hospital care. Although many occupational groups are required to hold a first aid qualification, for events, first aiders must be tasked specifically for first aid/medical duties. It is not acceptable for staff to have dual roles e.g. a crowd controller with a first aid qualification is first and foremost a crowd controller. Although an incident may be attended by a crowd controller who holds a first aid qualification initially, the patient should be referred to a designated first aider as soon as practicable so that the primary crowd control responsibilities are maintained. Competence and skill levels vary between providers. It is important for event organisers to confirm that the services they are purchasing match the competencies with the Table 1 Injury Profile and that their staff are appropriately trained and resourced to deal with these patients e.g. It is no good just having first aid personnel on site if they do not have any equipment to deal with emergencies.
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TABLE 2: Australian Qualifications Training Framework (AQTF) ET Intubation
IV therapy
Needle Cric.
Chest decomp.
ACLS
x
x
x
x
x
x
x
x
x
x
x
x
HLTFA201A
Provide basic emergency life support
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
HLTFA301C
Apply first aid
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
HLTFA302B
Provide first aid in remote situation
x
x
x
x
x
x
x
x
x
x
x
x
x
HLTFA402C
Apply advanced first aid
x
x
x
x
x
x
x
x
x
x
x
x
HLTFA403B
Manage first aid in the workplace
x
x
x
x
x
x
x
x
x
x
x
x
x
x
HLTFA404B
Apply advanced resuscitation techniques
x
x
x
x
x
x
x
x
x
x
x
x
x
HLT21112
Certificate II in Emergency Medical Service First Response
x
x
x
x
x
x
x
x
x
x
x
x
HLT33112
Certificate III in Basic Health Care
x
x
x
x
x
x
x
x
x
x
x
x
HLT30212
Certificate III in Non-Emergency Client Transport
x
x
x
x
x
x
x
x
x
x
x
HLT41012
Certificate IV in Health Care (Ambulance)
x
x
x
x
x
Diploma of Paramedical Science (Ambulance) Advanced Diploma of Paramedical Science (Ambulance)
x
x
x
HLT50412 HLT60307
x
Combitube or LMA
x
Transport
x
Medication Ventolin
Spinal immob.
x
Medication Glucagon
Auscultate BP
x
Medication Penthrane
Nasal airway
Medication Pigpen
Oral airway
Perform CPR
AED
HLTCPR211A
Australian Qualifications Training Framework (AQTF)
CPR
Oxygen delivery
The following table identifies names commonly used to describe medical personnel. It outlines various skill levels and competencies by the AQTF.
1
Common Terminology
Senior First Aid Advanced First Aid Certificate IV in Health Care – MEDIC Paramedic Intensive Care Paramedic
Please provide comment on:1. Does Table 2 adequately match the skills required to address the identified casualties? 2. Are there skills other than medical that need to be considered? 3. Is there any way in which clarity or accuracy can be improved?
Major incidents In the event of a major incident or multiple serious casualties above the pre event estimates, the first aid or ambulance provider must immediately advise the DOH Duty Officer on (08) 93280553, who may activate the local emergency services if additional resources are required. In the event of a major incident at an event requiring a St John Ambulance WA response, the St. John Ambulance Team leader will assume command of the scene in accordance with the Westplan Health Emergency Plan.
First aid posts Basic requirements for a first aid post:•
Must be conspicuous
•
Must be easily identified by an illuminated sign and well lit at night
•
Ideal locations are near the main entry or places where they can be viewed from entertainment locations or primary pedestrian routes.
•
Located close to where life threatening emergencies are likely to occur.
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•
Allow ambulance access for when a patient may need to be transferred to hospital.
•
Provide shelter and privacy for personnel and patients during assessment and treatment.
•
Provide a sheltered area with seats for patients waiting to receive treatment or under observation.
Medical equipment It is recommended that oxygen equipment, semi-automatic defibrillator and basic first aid supplies are available at every event. All first aid and medical services providers should have appropriate professional indemnity insurance for their personnel. The requirement for ambulance attendance at events should be determined using the risk assessment tools and a medical plan to determine the availability of an on-site ambulance and include a contingency in the event that an onsite ambulance leaves the site. The likelihood of a life threatening casualty and the time for an off-site ambulance to attend must be considered. Competence and skills vary between providers. It is important for event organizers to confirm that the services they are purchasing match the training skills on the Medical Response Matrix.
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Guideline 3: Reporting A basic medical report should be provided to the event organiser and DOH
[email protected] detailing the items listed below within seven days of the event. Interim verbal reports should be available during the event on request to the event organiser or environmental health officer. The intent of reporting is to determine where issues arise so that improvements may be made during the event or for future events. Patient confidentiality must be respected at all times and personal details should not be included in these reports.
Please provide comment on:1. Does Table 3 – Medical Report (next page) cover all relevant casualty events? 2. Are there any other issues that need to be considered when reporting first aid statistics? 3. Would first aid practitioners use a standard generic patient report 4. What issues would you most like to discuss or see raised at the First Aid Workshop on the 6th December?
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TABLE 3: Medical Report Presentation
Number
Hospital Transfer
Comment
Allergy / anaphylaxis Respiratory - Asthma Respiratory – Other Bites / stings Sun burn Cardiac Dehydration Drug related Alcohol related Heat exhaustion / stroke Hypothermia / cold Eye injury/irritation Headache Mental health Medical – seizures Medical – vomiting Medical – other Minor cuts/grazes Fracture / dislocation Head injury Soft tissue Spinal injury Unconscious Other? (include conditions not listed)
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Attachment Medical Services Providers The providers below have attended previous events, they have been included to assist event organizers identify organisations that may be able to provide first aid services. Their inclusion in the guidelines is not an endorsement of their ability to meet the intent of these guidelines, provide appropriate services or comply with any statutory requirements.
First Aid Providers •
St John Ambulance WA
•
Advanced Medical Support.
•
Sports Medicine Australia.
•
Royal Life Saving Society of Australia.
•
Surf Life Saving Association.
•
First Aid Services WA (Red Cross)
•
Medic One
•
Medical Hands
•
Event Health Management
Ambulance Services •
St John Ambulance Service WA (Statewide contractor)
•
Advanced Medical Support
•
Medic One
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© Department of Health 2013
