title: Mass-gathering Events: The Role of Advanced Nurse Practitioners in Reducing Referrals to Local Health Care Agencies.
abstract: Introduction: The introduction of advanced practitioner roles has challenged the traditional boundaries of health care. While studies have been undertaken to understand the role of physicians in respect of mass-gathering medicine, the role of advanced nurse practitioners (ANPs) has not been investigated. Problem Does the presence of an ANP reduce the referral rates of patients presenting for medical care at mass-gathering events to external health care resources?
  
  
  METHODS
  A prospective observational study was undertaken to determine whether the presence of an ANP would reduce the patient referral rate to external health care services by first aiders and paramedics working within an event medical team. Patients identified as requiring referral were reviewed by an ANP as part of the on-site medical provision for four mass-gathering events in the south of England. Additionally, information was gathered identifying which patients would have been transported to hospital by ambulance compared to those actually transported following ANP review. Statistical analysis was undertaken for three key measures (referrals to all local health resources, referrals to hospital-based acute services, and transfers to hospital by ambulance).
  
  
  RESULTS
  A rounded total of 842,000 people attended four mass-gathering events held over 14 days. Of these, 652 presented for medical care, many self-referring. Using a one-tailed Fisher's Exact Test and Phi analysis, this study demonstrated statistically significant reductions in the overall referral of patients to all external health care resources (P<.001; φ=0.44), to the emergency department (ED; P<.001; φ=0.43), and a reduction in ambulance transport (P<.001; φ=0.42). Effect size analysis demonstrated a medium-sized effect evident for all of the above, which was also demonstrated in economic terms. The event medical team would have referred 105 (16.3%) of the 652 patient presentations to external health care services; 47 (7.2%) would have been transported by ambulance. In comparison, the ANP referred 23 patients (3.5%) with 11 (1.7%) being transported by ambulance. It also was noted that the first aiders and paramedics could be more selective in their referral habits that were focused primarily on the ED.
  
  
  CONCLUSIONS
  Appropriately trained and experienced ANPs working within event medical teams have a positive impact on referral rates from mass-gathering events.
authors.affiliation: 1British Association for Immediate Care (BASICS),Ipswich,United Kingdom.
authors.forename: Anthony E
authors.initials: AE
authors.lastname: Kemp
mesh_terms: D000846:Anniversaries and Special Events; D003441:Crowding; D006268:Health Facilities; D006801:Humans; D009722:Nurse Practitioners; D024802:Nurse's Role; D011446:Prospective Studies; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D014187:Transportation of Patients / Q000706:statistics & numerical data*; D006113:United Kingdom
keywords: ANP advanced nurse practitioner; BRC British Red Cross; ED emergency department; HCP health care practitioners; MIU minor injuries unit; NHS National Health Service; PCS primary care services; PPR patient presentation rate; RTHR refer to hospital rate; RTLHCR refer to local health care rate; TTHR ambulance transport to hospital rate; UK United Kingdom; admission avoidance; advanced nurse practitioner; mass-gathering events; mass-gathering medicine; prehospital emergency care