Epidemiology of emergency
transport at sports stadiums andfacilities in Japan
Shinichirou Nakaze1,2, Koshi Nakagawa1, Shota Tanaka3,
Yosuke Homma1,4, Hideharu Tanaka1,3

Original ResearchpISSN 2671-793X eISSN 2671-7948
J EMS Med 2024;3(1):1-10
https://doi.org/10.35616/jemsm.2023.00045

Received: July 12, 2023
Revised: September 29, 2023
Accepted: October 16, 2023
Correspondence to:
Shinichirou Nakaze
Graduate School of Emergency
Medical System, Kokushikan
University, 7-3-1, Nagayama, Tama
City, Tokyo 206-8515, Japan
E-mail: shnakaze@gmail.com

1

Graduate School of Emergency Medical System, Kokushikan University, Tokyo, Japan
Teikyo University Institute Sports Science & Medicine, Tokyo, Japan
3
Research Institute of Disaster Management and EMS, Kokushikan University, Tokyo, Japan
4
Department of Emergency Medicine, Chiba Kaihin Municipal Hospital, Chiba, Japan

2

Objective: In recent years, large-scale sports events have been held in Japan, making it
necessary to ensure a strategic and systematic emergency medical system in stadiums. This
study aimed to clarify the characteristics of emergency medical care at stadiums and sports
facilities in Japan.
Methods: This cross-sectional study used national emergency transport data recorded from2015 to 2019. The study population included all emergency transport cases that occurredat athletic fields, stadiums, and sports facilities throughout Japan. Cases during competition
were classified into sports-related emergency transport incidents (SrETi) and non-SrETi(NSrETi). Multivariable logistic regression analysis was used to examine factors associatedwith severity.
Results: In total, 26,710,631 individuals were registered (14,078 SrETi, 15,458 NSrETi,
29,536 total). In the SrETi group, nine participants (0.06%) died, four (0.03%) became seriously ill, and 313 (2.22%) sustained serious injuries. In the NSrETi group, 92 participants(0.60%) died, 17 (0.10%) became seriously ill, and 882 (5.71%) sustained serious injuries.
Factors associated with the severity of injuries included being in the NSrETi group (adjusted
odds ratio [AOR], 1.52; 95% confidence interval [CI], 1.29-1.76) and the incident taking
place in a toilet (AOR, 1.84; 95% CI, 1.09-3.12), a swimming pool (AOR, 3.67; 95% CI, 2.834.77), or other locations (AOR, 1.26; 95% CI, 1.08-1.46) (vs. the ground).
Conclusion: Severe illnesses and injuries occurred not only among competitors but also
among non-athletes (e.g., spectators and staff). Training of first responders and strategic
placement of automated external defibrillators should also be considered for future sports
events.
Keywords: Emergency transport; Emergency medical system; Spectator medicine; Largescale sports events© 2024 Korean Council of EMS PhysiciansThis is an Open Access article distributed
under the terms of the Creative Commons
Attribution Non-Commercial License(http://creativecommons.org/licenses/
by-nc/4.0/) which permits unrestricted
non-commercial use, distribution, andreproduction in any medium, provided theoriginal work is properly cited.

www.jemsmed.org

INTRODUCTION
The Rugby World Cup, Olympics, and Paralympics were recently hosted in Japan aslarge-scale sporting events. The Tokyo 2020 Summer Olympics involved 11,420 athletes
and 312,883 officials from 206 countries [1], while the 2019 Rugby World Cup attracted 1,704,443 spectators, averaging 37,877 spectators per game [2]. These large-scale
sporting events are viewed as mass gatherings with a potential for injuries and illnesses

1Nakaze S et al.

Emergency transport at stadiums in Japan[3]. Therefore, stadium emergency medical systems must be
prepared to handle not only athletes, but also spectators and officials [4]. To establish an adequate emergency medical system, it
is crucial to understand the patterns of injuries and illnesses that
occur among athletes and spectators.
Kiyohara et al. [5] reported on sports-related emergency transports that took place in Osaka over the past 3 years. Out of the2,642 transports, 701 (25.5%) were due to fractures/bone contusions, making them the most common, followed by 667(24.2%) cases of bruises. Hirschhorn et al. [6] analyzed sports
injuries requiring emergency transport among high school andcollege students across the United States. Of the 485 case visits,
82 (16.9%) were fractures, the most common injury, followed by
73 (15.1%) concussions. There are numerous reports of sports
injuries both in Japan and globally, where athletes were injured
during competition and required emergency transport [6].
Conversely, Tajima et al. [4] conducted a study focusing onspectators, finding that 15.8% of spectators who were rushed tothe hospital during the tournament suffered from heat stroke andfractures and/or dislocations respectively. The highest incidence
was among men in their 70s, followed by men in their 80s [2].
Additionally, the most frequent transport time was just before
the start of the game [2]. However, to develop an emergency
medical system that includes spectators, it is necessary to have
epidemiological information not only for a specific period but
also for the entire year. Moreover, Tajima et al. [4] did not reporton the locations of injuries and illnesses. Therefore, to build an
emergency medical system that includes not only athletes but
also spectators and related parties, it is necessary to understandthe detailed characteristics of emergency patients throughout theentire sports stadium.

manned by three emergency medical technicians. At least one ofthese technicians is an emergency life support technician, capable of performing advanced life support. In 2022, there were
6,193,581 EMS dispatches, with a national average of 9.4 minutes from the time of the call to the arrival of the EMS, and 42.8
minutes from the call to hospital admission [7].
In Japan, large-scale sports events are coordinated by organizing committees, with the medical committee overseeing the
medical aspects. The emergency medical system involves professionals such as physicians, nurses, emergency medical technicians, athletic trainers, and volunteers [8]. The system ensures
the availability of nearby medical facilities and the presence of
medical professionals, including physicians and nurses, at the
sports venue. This is achieved by establishing medical stations,which form the backbone of the medical care system. For every
10,000 spectators, it is recommended to have one physician andtwo nurses on site [9]. Subsequently, the on-site response prioritizes sports volunteers, with a particular emphasis on emergency
medical technicians. These individuals, trained as sports first responders, receive specific education that enables them to perform basic life support, use automated external defibrillators(AEDs), and provide first aid. The number of AEDs installed isgenerally determined by the size of the sports facility, with at least
one unit required and additional units added as needed.

Study data

This cross-sectional study utilized national emergency transport
data collected between January 1, 2015, and December 31, 2019.
The Ethics Committee of the Kokushikan University approved
the study (approval number 23003).

The Fire and Disaster Management Agency (FDMA) provided
emergency transport data for sports grounds, stadiums, andsports facilities from 2015 to 2019. The exclusion criteria wereas follows: (1) locations other than athletic fields, stadiums, andvarious sports facilities; (2) incomplete location details; (3) incidents related to fire, natural disasters, or self-inflicted injuries;(4) transportation to hospitals; (5) missing gender data; and (6)time-variable outliers, defined as instances where the time between the call and patient contact was 30 minutes or more, or
the time between the call and hospital admission was 98 minutes or more. Data from the Tokyo Fire Department, Inagi City,and the islands of Tokyo were also excluded due to insufficientand missing data.

Study setting

Data collection and quality control

METHODS
Study design

2

In 2021, Japan, which spans an area of 378,000 km and comprises 47 prefectures, had a population of approximately 125 million.
The country's emergency medical services (EMS) are provided
around the clock by fire departments. In response to an emergency call, the closest EMS unit is dispatched, with each ambulance

2

The FDMA maintains an emergency transport database, and details about the data collection process have previously been reported [10]. The severity of incidents is categorized as follows:(1) death, which is confirmed at the time of the initial clinical examination; (2) severe, indicating a life-threatening situation suchhttps://doi.org/10.35616/jemsm.2023.00045

J EMS Med 2024;3(1):1-10

as cardiac or respiratory arrest, or a critical condition that necessitates cardiopulmonary resuscitation; (3) serious, which could
potentially be life-threatening; (4) moderate, not life-threatening
but requiring hospitalization; and (5) minor, not requiring hospitalization. The initial physician determines the severity upon
the patient's arrival at the hospital, using the severity classification table provided by the FDMA [7].

Outcomes

The outcome was categorized as either severe or greater (encompassing death, serious, or severe cases), or as moderate or minor inseverity. According to the FDMA definition, cases classified as“death/serious/severe” are considered life-threatening, while
those labeled as “moderate/minor” are deemed non-life-threatening. Classification was conducted based on these categories[7,11]. It is essential to prevent illnesses and injuries associatedwith life-threatening situations that may arise in sports facilities.
Consequently, understanding the characteristics of illnesses andinjuries classified as severe or greater is of paramount importance.

Study variables

The variables examined in this study encompassed: (1) the typeof incident, which was categorized into sports-related emergency
transport incidents (SrETi) and non-SrETi (NSrETi); according
to the FDMA's classification of accident types, SrETi was definedas "incidents involving athletes, referees, and other related parties
that took place during athletic competitions"; (2) location, which
included sports grounds, corridors, stairways, toilets, bathrooms(inclusive of showers and washrooms), gymnasiums, dojos,
swimming pools, and other locations; (3) season, divided into
spring (March to May), summer (June to August), fall (September to November), and winter (December to February); (4) age
group, segmented into children ( < 12 years old), adolescents anduniversity students (13–22 years old), young adults (23–35 years
old), middle-aged adults (36–64 years old), and the elderly ( > 64
years old); (5) severity, classified as death or serious, severe, andmoderate or minor; (6) time of call entry, broken down into
morning (6:00–11:59), afternoon (12:00–17:59), and night(18:00–5:59); and (7) the duration from the call-in to patient
contact and subsequent arrival at the hospital.

Statistical analysis

Continuous variables were expressed as means and standard deviations, while categorical variables were presented as numbers
and percentages. Descriptive statistics were employed to summarize the number of injuries and illnesses based on accident

https://doi.org/10.35616/jemsm.2023.00045

type and severity. To identify factors associated with severity, multivariable logistic regression analyses were utilized to estimate adjusted odds ratios (AORs) and 95% confidence intervals (CI).
The independent variables included accident type, season of occurrence, time of emergency call, sex, age, and location of occurrence. Covariates were chosen based on previous studies and clinically significant factors, using the direct entry method [12]. JMP
Pro Ver 15.0 (SAS Institute) was the software used for statisticalanalyses, with the significance level set at 5%.

RESULTS
Between January 1, 2015, and December 31, 2019, a total of
26,710,631 patients were registered in the emergency transport
database. Of these, 29,536 patients met the criteria for inclusion inthis study. These patients were categorized into two groups: SrETi(n = 14,078; 47.7%) and NSrETi (n = 15,458; 52.3%), as shownin Fig. 1. The characteristics of these patients are detailed in Table
1. The highest number of incidents occurred during the summer,
accounting for 10,550 (35.7%) of the total incidents. Of these,
5,209 (37.0%) were SrETi and 5,341 (34.6%) were NSrETi. The
most common time for call entries was between noon and the afternoon, with 15,766 (53.4%) calls. Of these, 7,645 (54.3%) were
SrETi, and 8,121 (52.5%) were NSrETi. Males made up the majority of the cases (n = 21,096; 71.4%). In the SrETi group, thelargest patient demographic (n = 6,464; 45.9%) was between 13
and 22 years old. In contrast, the NSrETi group had the highest
number of patients (n = 5,311; 34.4%) who were over 64 years
old. For SrETi incidents, the most common location was the
sports ground (n = 8,164; 58.0%), followed by the gymnasiumand dojo (n = 4,110; 29.2%). Similarly, 4,415 (28.6%) of NSrETi
incidents occurred on sports grounds, and 2,788 (18.0%) took
place in gymnasiums and dojos. However, unlike the SrETi group,
NSrETi incidents also occurred in corridors (n = 881; 5.7%), on
stairways (n = 222; 1.4%), in toilets (n = 172; 1.1%), and in bathrooms (n = 557; 3.6%). The NSrETi group had more severe cases,
including 92 deaths (0.6%) and 17 serious illnesses (0.1%), compared to the SrETi group, which had nine deaths (0.06%) and
four serious illnesses (0.03%).
In the SrETi group, there were 71 instances of severe or greater
illnesses and injuries, while the NSrETi group had 621 such cases. Conversely, SrETi reported 2,429 cases of moderate or minor
illnesses and injuries, and NSrETi reported 4,084 cases (Figs. 2,3). Due to missing values in the disease and injury data from
FDMA, percentages were calculated based on the total patient
count. Table 2 provides a summary of the characteristics of SrETi

3

Nakaze S et al.

Emergency transport at stadiums in Japan

26,710,631 All emergency transports in Japan, 2015–2019

26,560,663 Locations of occurrence other than athletic fields,
stadium, sports facilities

10,636 Tokyo Fire Department, Inagi City, Tokyo Islands

108,755 Exclusion of master category "225: Places of occurrence
other than athletic field, stadiums, and sports facilities"
210 Accident type: fire, natural disaster, self-inflicted injury,transfer to hospital

282 Missing data on sex

30,085 Emergency transport incidents occurring on athletic fields,
stadium, sports facilities
351 Contact from call to EMS ≥30 min
198 Arrival Hospital from call to EMS ≥98 min

29,536 Eligible for analysis

14,078 Sport-related emergency transport incident

15,458 Non-sport-related emergency transport incident

Fig. 1. Flowchart for identifying emergency transport cases that occurred in athletic stadiums. EMS, emergency medical services.

and NSrETi where the initial physician rated the severity as severe or greater. In this context, SrETi accounted for 326 cases(24.8%), and NSrETi accounted for 991 cases (75.2%). The
most common severe or greater illnesses and injuries in SrETi
and NSrETi were non-union fractures (35.2%) and brain diseases (45.6%), respectively. On the other hand, the most common
moderate or minor illnesses and injuries in SrETi and NSrETi
were bruises (39.2%) and brain diseases (16.1%), respectively.
The results of the multivariable logistic regression analysis are
displayed in Table 3. NSrETi were found to be significantly associated with severity (AOR, 1.52; 95% CI, 1.29–1.76) when compared to SrETi. Patients who were less than 13 years old (AOR,

40.10; 95% CI, 0.07–0.14), between 13 and 22 years old (AOR,
0.20; 95% CI, 0.17–0.25), between 23 and 35 years old (AOR,
0.36; 95% CI, 0.29–0.44), and between 36 and 64 years old(AOR, 0.75; 95% CI, 0.65–0.87) were significantly more associated with severity than patients who were older than 64 years. The
locations of a toilet (AOR, 1.84; 95% CI, 1.09–3.12), swimming
pool (AOR, 3.67; 95% CI, 2.83–4.77), and other unspecified locations (AOR, 1.26; 95% CI 1.08–1.46) were also significantly
associated with severity when compared to the sports ground.
Multivariable logistic regression analysis demonstrated a significantly higher occurrence of severe or greater illnesses and injuries in toilets, swimming pools, and other locations. Fig. 4 illus-

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J EMS Med 2024;3(1):1-10

Table 1. Characteristics of emergency transport cases in SrETi and NSrETi events in Japan
Variable
SeasonTime of call to EMS

SexCategory
SpringSummerAutumnWinter
6:00–11:59
12:00–17:59
18:00–5:59
MaleFemaleAge, yrAge group< 13 yr
13–22 yr
23–35 yr
36–64 yr
> 64 yr
Location
GroundCorridor
Stairway
ToiletBathroom/shower/washroom
Gymnasium/dojo
Swimming pool
Other location
Severity
Death
Serious
SevereModerate
Minor
OthersTime of call to contact, min Contact from call to EMS
Arrival hospital from call to EMS

Total (n = 29,536)
6,807 (23.0)
10,550 (35.7)
7,190 (24.3)
4,989 (16.9)
9,807 (33.2)
15,766 (53.4)
3,963 (13.4)
21,096 (71.4)
8,440 (28.6)
36.6 ± 24.3
3,625 (12.3)
9,270 (31.4)
3,926 (13.3)
6,757 (22.9)
5,958 (20.2)
12,579 (42.6)
1,026 (3.5)
225 (0.8)
178 (0.6)561 (1.9)
6,898 (23.4)
709 (2.4)
7,360 (24.9)
101 (0.3)
21 (0.1)
1,195 (4.0)
7,959 (26.9)
20,185 (68.3)
75 (0.3)
9.9 ± 4.2
36.4 ± 13.7

SrETi (n = 14,078)
3,432 (24.4)
5,209 (37.0)
3,612 (25.7)
1,825 (13.0)
4,673 (33.2)
7,645 (54.3)
1,760 (12.5)
11,232 (79.8)
2,846 (20.2)
26.2 ± 16.9
1,813 (12.9)
6,464 (45.9)
2,408 (17.1)
2,746 (19.5)
647 (4.6)
8,164 (58.0)
145 (1.0)
3 (0.0)6 (0.0)4 (0.0)4,110 (29.2)
53 (0.4)
1,593 (11.3)
9 (0.0)4 (0.0)313 (2.2)
3,813 (27.1)
9,909 (70.4)
30 (0.2)
9.6 ± 3.9
35.3 ± 13.2

NSrETi (n = 15,458)
3,375 (21.8)
5,341 (34.6)
3,578 (23.1)
3,164 (20.5)
5,134 (33.2)
8,121 (52.5)
2,203 (14.3)
9,864 (63.8)
5,594 (36.2)
45.9 ± 26.1
1,812 (11.7)
2,806 (18.2)
1,518 (9.8)
4,011 (25.9)
5,311 (34.4)
4,415 (28.6)
881 (5.7)
222 (1.4)
172 (1.1)
557 (3.6)
2,788 (18.0)656 (4.2)
5,767 (37.3)
92 (0.6)
17 (0.1)
882 (5.7)
4,146 (26.8)
10,276 (66.5)
45 (0.3)
10.2 ± 4.5
37.3 ± 14.1

Values are presented as number (%) or mean±standard deviation.
SrETi, sports-related emergency transport incidents; NSrETi, non-SrETi; EMS, emergency medical services.

trates the proportion of NSrETi cases in these places. In swimming pools, cardiac disease accounted for the greatest number ofcases (n = 38; 45.8%), followed by brain disease (n = 30; 36.1%).
Similarly, in other locations, cardiac disease was the most common cause of incidents (n = 108; 33.2%), followed by brain disease (n = 103; 31.7%). In toilets, brain disease was the most common cause of incidents (n = 10; 58.8%), followed by cardiac disease (n = 2; 11.8%).

DISCUSSION
To the best of our knowledge, this is the first study to examine

https://doi.org/10.35616/jemsm.2023.00045

the characteristics of patients transported from sports stadiums
and facilities using FDMA emergency transport data. The results
indicated that SrETi patients were more frequently rushed to thehospital due to injuries, while NSrETi patients were more oftentransported due to illnesses. Moreover, SrETi cases were primarily classified as moderate or minor, and not directly life-threatening. In contrast, NSrETi cases encompassed more severe and potentially life-threatening illnesses, which were more common inswimming pools, toilets, and other locations. The epidemiology
of diseases occurring at athletic fields and sports facilities, as
identified by this study, could enhance the prognosis of injured
and ill patients when athletic trainers, physicians, and EMS are

5

Nakaze S et al.

Emergency transport at stadiums in Japan(n=692)
35.2%

Fracture

7.7%
18.3%

Cardiovascular disease
Dislocation/sprain

43.8%
12.7%
0.6%
11.3%

Brain disease
Spinal nerve injury
BruiseOpen fracture
Contusion

45.6%
11.3%
1.1%
5.6%
0.3%
4.2%
0.5%

■ SrETI (n=71)
■ NSRETi (n=621)

1.4%
0.3%

Fig. 2. Number of illnesses and injuries (71 SrETi and 621 NSrETi) that were severe or greater in athletic fields. “Others” was excluded.
Due to some missing values in the Fire and Disaster Management Agency dataset for the number of illnesses and injuries, it was
expressed in percentage. SrETi, sports-related emergency transport incidents; NSrETi, non-SrETi.

(n=6,513)
BruiseDislocation/sprain

20.6%
8.4%
8.1%
6.8%

Contusion

Brain disease
Mental illness
Respiratory disease
Sensory disease
Cardiovascular disease
Digestive disease

23.5%

6.2%

Fracture

Spinal nerve injury

39.2%

14.1%

2.1%
0.5%
2.0%

16.1%

1.6%
1.0%

9.4%
4.5%

0.9%

12.9%

0.7%
0.5%

14.1%
7.0%

■ SrETI (n=2,429)
■ NSRETi (n=4,084)

Fig. 3. Number of illnesses and injuries (2,429 SrETi and 4,084 NSrETi) that were moderate or minor in athletic fields. "Other" wasexcluded. Due to some missing values in the Fire and Disaster Management Agency dataset for the number of illnesses and injuries, it
was expressed in percentage. SrETi, sports-related emergency transport incidents; NSrETi, non-SrETi.

6

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J EMS Med 2024;3(1):1-10

Table 2. Characteristics of SrETi and NSrETi events in cases rated as severe or greater
Variable
SeasonCategory

SpringSummerAutumnWinterTime of call 6:00–11:59
to EMS 12:00–17:59
18:00–5:59
Sex
Male
FemaleAge, yrAge group < 13 yr
13–22 yr
23–35 yr
36–64 yr
> 64 yr
Location Ground
Corridor
Stairway
ToiletBathroom/shower/washroom
Gymnasium/dojo
Swimming pool
Other location

Total
SrETi
NSrETi(n = 326)(n = 991)
84 (25.8) 255 (25.7)
100 (30.7)
216 (21.8)
94 (28.8) 266 (26.8)
48 (14.7) 254 (25.6)
134 (41.1)
400 (40.4)
148 (45.4)
481 (48.5)
44 (13.5)
110 (11.1)
264 (81.0)725 (73.2)
62 (19.0) 266 (26.8)
37.3 ± 21.6 60.5 ± 18.6
17 (5.2)
18 (1.8)102 (31.3)
42 (4.2)
54 (16.6)
62 (6.3)
104 (31.9)
343 (34.6)
49 (15.0) 526 (53.1)
160 (49.1) 236 (23.8)
2 (0.6)57 (5.8)0
12 (1.2)
017 (1.7)
032 (3.2)
100 (30.7)
3 (0.9)61 (18.7)

127 (12.8)
91 (9.2)
419 (42.3)

Death
SrETi
NSrETi(n = 9)(n = 92)
3 (33.3)
27 (29.3)
1 (11.1)
17 (18.5)
4 (44.4)
26 (28.3)
1 (11.1)
22 (23.9)
3 (33.3)
39 (42.4)
3 (33.3)
40 (43.5)
3 (33.3)
13 (14.1)
7 (77.8)
71 (77.2)
2 (22.2)
21 (22.8)
59.0 ± 13.1 68.5 ± 13.0000
1 (1.1)1 (11.1)
1 (1.1)5 (55.6)
22 (23.9)
3 (33.3)
68 (73.9)
2 (22.2)
22 (23.9)0
3 (3.3)000
4 (4.3)0
9 (9.8)5 (55.6)
1 (11.1)
1 (11.1)

5 (5.4)14 (15.2)
35 (38.0)

Serious
SrETi
NSrETi(n = 4)(n = 17)
1 (25.0)
5 (29.4)
1 (25.0)
4 (23.5)
1 (25.0)
5 (29.4)
1 (25.0)
3 (17.6)
3 (75.0)8 (47.1)
1 (25.0)8 (47.1)0
1 (5.9)3 (75.0)
13 (76.5)
1 (25.0)
4 (23.5)
35.5 ± 24.5 63.2 ± 13.9
00
2 (50.0)00
1 (5.8)2 (50.0)
6 (35.3)
0
10 (58.8)
2 (50.0)
7 (41.2)
0
0
0
0
0
0
0
0
0
0
2 (50.0)

4 (23.5)
2 (11.8)
4 (23.5)

SevereSrETi
NSrETi(n = 313)(n = 882)
80 (25.6) 223 (25.3)
98 (31.3)
195 (22.1)
89 (28.4) 235 (26.6)
46 (14.7) 229 (26.0)
128 (40.9) 353 (40.0)
144 (46.0) 433 (49.1)
41 (13.1)
96 (10.9)254 (81.2)
641 (72.7)
59 (18.8)
241 (27.3)
36.7 ± 21.5 59.6 ± 19.0
17 (5.4)
18 (2.0)100 (31.9)
41 (4.6)
53 (16.9)
60 (6.8)
97 (31.0)315 (35.7)
46 (14.7) 448 (50.8)
156 (49.8)
207 (23.5)
2 (0.6)54 (6.1)
0
12 (1.4)
0
13 (1.5)
023 (2.6)
95 (30.4)
2 (0.6)58 (18.5)

118 (13.4)
75 (8.5)
380 (43.1)

Values are presented as number (%) or mean±standard deviation.
SrETi, sports-related emergency transport incidents; NSrETi, non- SrETi; EMS, emergency medical services.

actively providing emergency medical care.
The findings of this study suggest that serious emergency medical incidents at athletic fields and stadiums are more frequently
non-sports-related than sports-related. Traditionally, sports-related emergency medical systems and AED placement have beenviewed as relief strategies primarily for athletes [13]. However, inline with the suggestions made by Borjesson et al. [14], the results of our study underscore the necessity for emergency medical systems that cater to non-athletes, including staff and spectators, at large-scale sporting events. Besides injuries, illnesses arealso prevalent among spectators. Given that spectators are typically older than athletes and are more likely to have complex
medical histories, they are at a heightened risk. As evidenced by
the Tokyo 2020 Olympics, first aid preparedness in athletic stadiums and sports facilities should account for both injuries among
competitors and non-sports participants.
This study found that the incidence of NSrETi was signifi-

https://doi.org/10.35616/jemsm.2023.00045

cantly higher in toilets and other locations. The elevated incidence in toilets is thought to be due to the rapid rise in bloodpressure that occurs during straining for urination and defecation, which can trigger acute coronary syndrome and subarachnoid hemorrhage [15]. Out-of-hospital cardiac arrests (OHCA)
that occur in toilets often result in delayed patient discovery,leading to a poorer neurological prognosis [16]. An increased
incidence was also observed in spectator seating areas. The rateof OHCA rose during sports viewing [17-21], and the emotional stress experienced while watching sports can precipitate acutecardiovascular events [22-26]. The findings of this study underscore the importance of promoting awareness of relief in toilets
and spectator seating areas. Furthermore, AEDs should be strategically positioned in locations that are easily accessible fromtoilets and spectator seating areas.
Furthermore, the results of this study revealed that the incidence of severe disease significantly increased with age. As most7Nakaze S et al.

Emergency transport at stadiums in Japan

Table 3. Results from multivariable logistic regression analysis with factors related to severity
Variable
Accident type
SrETi
NSrETi
SeasonSpringSummerAutumnWinterTime of call to EMS
6:00–11:59
12:00–17:59
18:00–5:59
Sex
Male
FemaleAge group< 13 yr
13–22 yr
23–35 yr
36–64 yr
> 64 yr
Location
GroundCorridor
Stairway
ToiletBathroom/shower/washroom
Gymnasium/dojo
Swimming pool
Other location

Severe or greater % (n/N)

Multivariable analysis
AOR (95% CI)
P-value

2.3 (326/14,078)
6.4 (991/15,458)

Reference
1.52 (1.29–1.76)

5.0 (339/6,807)
3.0 (316/10,550)
5.0 (360/7,190)
6.1 (302/4,989)

1.53 (1.30–1.80)
Reference
1.45 (1.24–1.70)
1.60 (1.35–1.89)< 0.001

5.4 (534/9,807)
4.0 (629/15,766)
3.9 (154/3,963)

1.21 (1.07–1.37)
Reference
1.03 (0.85–1.25)

0.016

4.7 (989/21,096)
3.9 (328/8,440)

Reference
0.62 (0.54–0.71)

1.0 (35/3,625)
1.6 (144/9,270)
3.0 (116/3,926)
6.6 (447/6,757)
9.7 (575/5,958)

0.10 (0.07–0.14)
0.20 (0.17–0.25)
0.36 (0.29–0.44)
0.75 (0.65–0.87)
Reference

3.1 (396/12,579)
5.8 (59/1,026)
5.3 (12/225)
9.6 (17/178)
5.7 (32/561)
3.3 (227/6,898)
13.3 (94/709)
6.5 (480/7,360)

Reference
1.21 (0.90–1.62)
0.98 (0.54–1.80)
1.84 (1.09–3.12)
0.79 (0.54–1.16)
1.12 (0.94–1.33)
3.67 (2.83–4.77)
1.26 (1.08–1.46)< 0.001< 0.001< 0.001

0.712< 0.001< 0.001< 0.001< 0.001< 0.001

0.203
0.973
0.021
0.240
0.206
< 0.001
0.012

AOR, adjusted odds ratio; CI, confidence interval; SrETi, sports-related emergency transport incidents; NSrETi, non-SrETi; EMS, emergency medical
services.

cases of heart disease (n = 108; 33.2%) were classified as severe
and occurred in various locations, it is crucial to consider the rising number of spectators with age-related heart disease.
This study had several limitations. First, as an observational
study utilizing secondary emergency transport data, there may
have been confounding effects. Second, the cross-sectional nature of the study precludes the identification of causal relationships. Third, the study's generalizability to other countries andregions may be limited, given that it was conducted using emergency transport data from Japan. Fourth, the FDMA defines accidents resulting from athletic events as "accidents that occur
during the conduct of athletic events and that involve the direct8

conduct of athletic events, referees, and related personnel" [7].
As such, some non-athletes were included in the SrETi group.
In conclusion, this study investigated the characteristics of patients requiring emergency transport from athletic stadiums andsports facilities in Japan and found that the SrETi group mostly
involved moderate and minor non-life-threatening sports injuries. In contrast, the NSrETi group tended to include life-threatening illnesses and injuries, many of which occurred in swimming pools, toilets, or other locations. These results underscorethe importance of developing emergency medical systems not
only for athletes but also for staff and spectators, as well as strategic AED placement near toilets and spectator seating.

https://doi.org/10.35616/jemsm.2023.00045

J EMS Med 2024;3(1):1-10

A

B

Swimming
n=83
Swimmingpool
Pool n=83
132(15.7%)(2.4%)

30(36.1%)

Toiletn=17
Toilet n=17

diseasebrain disease■ Brain■ Cardiovascular disease■ Contusion
cardiovascular disease■ Other
contusion■ Brain disease
brain disease■ Cardiovascular disease■ Fracture
cardiovascular disease■ Other4(23.5%)

110(5.9%)(58.8%)

fracture

2
38

other

(11.8%)(45.8%)

C

Other
n=325
Other location
location n=325

87(26.8%)

103(31.7%)

4(1.2%)

other23

diseaseBrain
disease■brain■ Cardiovascular disease
Contusiondisease■cardiovascular■ Internal injury
fracture■ Otherinternal injury(7.1%)

108

other(33.2%)

Fig. 4. Breakdown of reasons for transporting non-sports-related emergency transport incidents events to swimming pool (A), toilet (B),and other location (C).

FUNDINGACKNOWLEDGMENTS

None.

We would like to express our gratitude to Professor Hiroshi
Takyu of Kokushikan University for his valuable comments on
the preparation of this document.

CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.

AUTHORS’ CONTRIBUTIONS
Conceptualization: SN; Formal analysis: SN, KN; Investigation:
SN; Methodology: SN, KN; Project administration: SN; Supervision: YH, HT; Visualization: SN; Writing–original draft: SN,
KN, HT; Writing–review & editing: SN, KN, YH, ST, HT.

ORCID
Shinichirou Nakaze, https://orcid.org/0009-0000-8135-5193
Koshi Nakagawa, https://orcid.org/0000-0001-8738-1261
Shota Tanaka, https://orcid.org/0000-0002-3191-9808
Yosuke Homma, https://orcid.org/0000-0002-0473-9617
Hideharu Tanaka, https://orcid.org/0000-0003-4565-0026

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