INTRODUCTION

The FIFA World Cup Qatar 2022™ (FWC2022) was unique in many ways, but most certainly in its demands on the healthcare resources in the only host city, Doha, and surrounding area—and in the opportunities for the medical service delivery arising from this setting.

While the State of Qatar looks back on an impressive history of hosting World Championships and World Cups across various sports, during which organisers accumulated vast experience in managing medical services at elite sports events, the sheer dimension of the largest single sport event in the world required strategising and planning of the most effective and efficient use of limited healthcare resources at an unprecedented level. According to FIFA, more than 1.4 million visitors—about half its population—came to Qatar over the course of the four weeks of the tournament. About 180’000 accredited staff worked at the event, 10’000 of them international media and broadcast and 20’000 volunteers. About 3.4 million spectators attended matches and 1.85 million visitors the fan festival. Thirty-two national team delegations, amounting to about 3000 persons in total with 832 players and hundreds of VIPs came to Doha, all of them expecting the highest level of care in anything they needed.

In essence, one medical service provider, Hamad Medical Corporation (HMC) with its various hospitals delivered care to all stakeholder groups except players, meaning workforce, VIPs, delegation members, broadcast and media, sponsors and partners, families of participants and spectators. One specialised sports medicine hospital, Aspetar, catered for all national teams’ medical and performance needs. In their planning and execution, both institutions defined one aim for themselves aligned with the event’s credo “Deliver amazing”: to provide the best medical services ever at a FIFA World Cup, and one that could be used as a blueprint for any future major sporting event held throughout the globe.

This setup enabled the development and installation of one Medical Command Centre (MCC) that would coordinate all medical matters concerning FWC2022 stakeholders throughout the entire tournament, resulting in substantial advantages from both the organiser and event owner perspective. The Medical Command Centre was considered the brain of the medical services provision and used a “hub and spoke” model. Critical incidents occurring within Qatar were fed to the MCC, allowing the MCC to strategise any medical event relating to the World Cup, using pre-determined emergency or clinical action plans. The MCC controlled all ambulance movements, organised transfers and admissions, family medicine and specialist appointments for all participants, notified FIFA Medical of all incidents in predefined groups of interest, created daily reports and was the gateway for team doctors in accessing any services, equipment or medication they needed outside of matches.

Various tournaments and events served as test events (FIFA Club World Cup 2020™, World Cup qualifiers, FIFA Arab Cup Qatar 2021™), but had obvious limitations in their comparability with the main tournament, for example, where it came to the size of patient and athlete populations. However, they proved the value of the central function of the MCC while allowing to identify flaws and gaps that could then be addressed before November 2022.

Overall, notwithstanding the concerns and risk of exhaustion or sudden overwhelm of the local resources in case of mass incidents or disease outbreaks, the compact nature of the medical service and the planning and delivery at the tournament proved to be a major advantage, facilitating monitoring and control by FIFA.

FIFA PLAYER HEALTH CONCEPT AT THE FWC2022

The player health concept at the FWC2022 centred on a highly standardised and structured approach to the emergency care delivery by the field-of-play (FoP) medical teams, player medical centre staff, equipment and team medical services. A concerted action to improve concussion management included, among others, baseline screening, the permanent concussion substitute trial, Concussion Assessment and Rehabilitation Service, education sessions for the referees and team medical staff and injury spotting using medical replay to identify injury mechanisms in general and red flags for a concussion.

Stadium medical infrastructure for players and match officials

FIFA defines the requirements for the facilities, equipment, staffing and communication applicable to the stadium medical services in their “Medical Handbook” that is provided to all local organisers in the planning phase. The focus is on standardising these factors in the medical service delivery to players and match officials as much as possible to establish ideal preconditions for the implementation and operations during the event. The Handbook describes the location and layout of the player medical centre, its access from the pitch and egress to the ambulance, the setup of the two patient bays, the devices and equipment for assessment (Appendix 1), monitoring and treatment, the medication and the staffing with one emergency medicine physician and a nurse. The centre is equipped to accept players with severe injuries or medical emergencies from the dressing rooms or pitch where immediate hospital transfer is not required. Team physicians may also use the centre and its equipment if they want to assess and treat players in a private and professional setting. FIG 1

Similarly, the Handbook describes the composition of the field-of-play medical team with two teams of one emergency medicine physician and three paramedics each. Their exact equipment for the safe assessment and extrication of players and the content of the emergency bag to provide resuscitation, other immediate care and preparing the transfer of an ill or injured player to the ambulance or player medical centre, was uniform between the eight stadia (Appendix 2). This was to ensure familiarity with the equipment, reinforced through the training sessions, and to also ensure continuity, should any of the teams need to cover another stadium.Fig 2&3

Furthermore, the Handbook stipulates two critical care ambulances that must be positioned with direct and unobstructed access to the pitch, ideally in the tunnels or gates at the two corners on the side of the participating team and medical team benches and the egress route in the stadium perimeter clearly marked on stadia maps.

FIFA Framework for Assessing and Extricating Players

In 2021, FIFA developed and started to implement the FIFA Framework for assessing and extricating players from the pitch. This framework is based on a consistent and structured assessment that is implemented in the same way each time to provide an optimal pitch-side medical response and ensure best player outcomes, known as the FIFA Medical Set-Piece. Similar to a set-piece that is rehearsed on the training ground to ensure complete familiarity between teammates, so too does the Medical Set-Piece rely on this rehersal ethos, to ensure full understanding of the individual jobs of each participant that come together to form a collective approach, giving the best chance for a successful and efficient medical response to an emergency.  Applying a default structure to every assessment balances knowledge, skills and experience on the one hand with human factors that may considerably influence such response on the other hand. The framework is described in detail in the new “FIFA Emergency Care Manual” published in 2022, that will be freely available online, to complement the Medical Handbook.

In October 2021, the two-day FIFA Emergency Care Course—Advanced Level was held in Doha, and all Q22 Venue Medical Managers and FoP emergency medicine doctors had to pass the final exam to participate in the tournament. This course was led by a professional emergency medicine instructor team that provided teaching and hands-on training in a 1:2 instructor-to-participant ratio.

The new FIFA Emergency Care Manual was sent in June 2022 to the Supreme Committee for Delivery and Legacy (SCDL)’s Medical Operations Manager to further inform the FoP medical teams’ training. The effort and diligence that went into the systematic and comprehensive online and practical training of the FoP medical teams for all stadia led to optimally prepared side-line teams that responded in a structured and consistent manner during all moulages and to incidents during matches at the FWC2022.

Engagement of participating member associations’ team physicians

The team physicians of the participating member associations are the key stakeholder group for FIFA Medical at any tournament. Any effort must be made to incorporate them into the medical structure and support them in their care delivery to players and delegation members in the best way possible. At the same time, the colleagues have full autonomy in their medical care delivery and decision making and always retain complete ultimate responsibility for their players’ welfare. Fig 4

In July 2022, a two-day workshop was held with the team physicians of all 32 participating member associations at Al Janoub stadium. The purpose of the two day course was to make the participants aware of the FIFA World Cup Emergency Medicine Course and the organisation of the medical services at the stadia that included an inspection of the player medical centre, the FoP medical team equipment and the critical care ambulances. Further, there was a that obtained feedback from the team physicians and explored their ideas regarding the concepts and priorities they wished to see included in a medical plan for the World Cup.

The Supreme Committee for Delivery and Legacy (SCDL) Chief Medical Officer presented the concept of the MCC, how to access medical services through the hotline number and Hamad Medical Corporation facilities. The Chief of Sports Medicine at Aspetar gave an overview of the specialist services available on site, including an innovative visual approach to radiological reporting.

Improving concussion management on and off the field of play and supporting the team doctors optimally remains at the centre of FIFA’s player health concept. The FIFA Medical Director provided an overview of the FWC2022 Medical Services and an introduction into the approach to concussion management at the tournament based on the FIFA Medical Concussion Protocol and the IFAB Permanent Concussion Substitute Trial supplemented by an independent Concussion Assessment and Rehabilitation Service offered by Aspetar.

For the first time at a FIFA tournament, a cardiology pathway (Sports Cardiology Review Examination Evaluation Needs (SCREEN) was offered to teams, where a mobile sports cardiology team was available to assess a player at the team hotel. Alternatively, players could be assessed at Aspetar by an experienced physician who would engage the team physician in the process and provide recommendations on the next steps.

After the workshop, a dedicated (Microsoft Teams) Microsoft channel was created for the team doctors where all information relating to the medical services at the FWC2022 was provided, including the circulars, forms, FIFA Medical Concussion Protocol, FIFA Emergency Care Manual, all presentations from the workshop, the Player Medical Centre and FIFA Emergency Care Bag equipment, COVID-19 Guidebook, hospitals and their services, contact details, processes to follow. Updates were provided in posts as needed. This allowed for direct interaction and avoided that team doctors, who do not access the Competitions Extranet for all participating teams or their email regularly, missed relevant information.

FIFA Venue Medical Coordinator and injury spotter

All FIFA Venue Medical Coordinators had successfully completed the FIFA Emergency Medicine – Advanced Level course before being posted full-time to one of the eight stadiums for the duration of the tournament. Their primary responsibility was the coordination of all player health issues at the stadium in support of the team physicians.

The FIFA Venue Medical Coordinators at the FWC2022 (Figure 5):

• inspected the player medical centre and and confirmed the compliance of its layout and equipment with FIFA requirements;
• assessed and confirmed the access route from the pitch to the centre and the egress route from the centre to the ambulance;
• confirmed the position of the player ambulances and the access route from the pitch and the egress route from the stadium;
• instructed and trained the field-of-play medical team prior to the start of the tournament;
• attended Match Coordination Meetings and presented the relevant medical matters to the teams;
• checked the contents of the FIFA Emergency Care Bag on a regular basis and ensured its immediate availability at the pitch side and on the pitch during matches;
• were the first point of contact for the team physicians of teams playing at the venue and met with team physicians before each match to determine and document the roles of all medical staff in case of an emergency (Pre-Match Emergency Action Plan (PEAP));
• provided medical leadership to the FoP team at all matches by
  • initiating and overseeing the moulages with the FoP medical teams prior to each match
  • monitoring the field of play
  • directing the FoP medical team
  • fulfilling the respective PEAP role assigned to them in each match
  • intervening in the management of injured or acutely ill players when necessary
  • assessing video recordings of injuries, discussing the incident with the injury spotter and providing the information to the team physician
• completed and submitted the match report;
• followed up with team physicians on any incidents of concern and assisted in the organisation of diagnostic and/or therapeutic services. fig 6

The FIFA Venue Medical Coordinator was supported by an injury spotter on the media tribune who had a large screen medical replay station. The spotters were trained to review injury mechanisms with a focus on head injuries and potential concussion suffered by players. The instruction manual summarised the potential video signs of a concussion and described the yellow and red flags for a concussion. Where identified, this would be communicated to the Medical Coordinator at the pitch side who would then relate these findings to the team physicians. Importantly, the final responsibility for withdrawal or continued play of a player lies entirely with the team physician at FIFA tournaments.

FIFA Pre-Match Emergency Action Plan

The Pre-Match Emergency Action Plan (PEAP) illustrates a process by which the FoP medical teams organise themselves at FIFA tournaments to deliver the best possible care in an emergency on the pitch. It is aimed at minimising the inherent risks when responding to a time-critical emergency in front of millions of spectators. The Pre-Match Emergency Action Plan links key clinical interventions with predetermined roles, thereby helping the FoP teams to manage the challenging human factors in this situation. The scripted and reproducible process replaces traditional reactive team dynamics with a proactive preparation model, based on the premise that the process for the emergency response remains the same regardless of the scenario. The PEAP necessitates team practice and scenario-based training by the field-of-play medical team to minimise stress and improve efficiency when called into action.

Within the PEAP, roles are allocated to team members and practiced so that everyone is aware of their role and responsibilities in the process. Roles are colour coded and represent the positions and responsibilities each member should take during a scenario. Before a match, the FIFA Venue Medical Coordinator discusses with the two team physicians which role they want to assume. Integrating the team physician in whatever role they choose into the FoP medical team is critical and a major responsibility of the FoP medical team. Team physicians are invited to join the pre-match moulages, but will mostly be unable to find the time to do so during their match preparations. The roles are documented in the PEAP and displayed in the player medical centre.

Fig 7

MEDICAL SERVICES AT OFFICIAL VENUES

Centralized services

Having the FWC2022 in one small country provided a unique opportunity to standardise medical services at official venues across the tournament and to centralise the command, control and reporting system of these services.

FWC2022 official venues included competition venues (all stadia), as well as non-competition venues (team base camps and training sites, FIFA VIP and staff accommodation, tournament headquarters and international media and broadcast centres).

Command, control and reporting

The Medical Command Centre started operations well before the start of the tournament and was available on a 24-hour per day and seven days per week basis. Representatives from all stakeholder groups, including Hamad Medical Corporation Ambulance Service, all hospitals, primary healthcare, Covid Compliance, Ministry of Public Health, etc., were seated in one command room to facilitate communication and problem-solving. There were also three on-call doctors at any given time, who were able to do in-room consultations at selected sites (see below).

The MCC served as the centralized coordination centre for all patient requests, hospital transfers and medical reports. Selected constituent groups, including all Team Liaison Officers, team physicians, FIFA and HC Guest Operations Managers (VIP & VVIP guests) and FIFA Medical were provided with a single telephone number for the MCC. These groups could request an online or in-room consultation with one of the on-call doctors, an appointment at a hospital or additional medications from the pharmacy (team physicians only) or enquire about and be directed to any medical services. The MCC assisted in decision-making and coordination of all player and VIP hospital transfers. Finally, the MCC recorded all medical encounters from tournament clinics, mobile medical staff and all tournament-affiliated hospitals.  This provided a unique opportunity to gather data on the number of patients seen across the tournament in a single, consistent format.

Standardised clinics

There were 118 clinics throughout the tournament, including 85 in the stadia, four in official accommodation venues, two in the official media and broadcast venues and one at the tournament headquarters. The remaining 26 clinics were in non-official venues. All clinics across the tournament were standardized to look the same and were set up like a mini-emergency room with all the necessary equipment, consumables and medications to manage most emergencies and acute care. The philosophy was that with standardized clinics, it is easy to rotate staff between clinics or for last-minute back-up staff to work in any clinic. Standardization also makes it easier for team physicians to use the player medical centre in any stadium. Once they had seen the equipment in one clinic and understood the layout, they knew what to expect in every stadium. Clinic inventories were created for each type of clinic, the layout provided to staff and checklists issued for their clinic to ensure quick and thorough checks at the start of every shift.

Training programme and rehearsals

One of the most significant advantages of a centralized system was the opportunity it provided to “tournament train” all 3500 medical staff. The Supreme Committee for Delivery and Legacy developed a very extensive blended training programme, combining online modules, practical workshops and stadium rehearsals, which were tailored to the role of each person.

Staff were divided into several groups according to their roles in the stadium:

• Venue Medical Managers
• Field-of-play and player medical centre doctors
• Field-of-play paramedics
• Player medical centre nurses
• Clinic doctors
• Clinic nurses
• Paramedics—they were trained independently by the HMC Ambulance Service.

Online modules

The following online modules were developed and offered to the various groups:

• General orientation (tournament, venue, electronic medical records, Medical Code of Conduct and special considerations)—all staff
• Player care—all field-of-play and player medical centre staff, as well as hospital doctors and nurses likely to receive players at the hospital
• Major incidence response—all staff.

• Face-to-face workshops
• In-person workshops were developed for specific groups:
• FoP training—all FoP staff (one or two full days, according to role)
• Major Incident training—all staff (one full day)
• Venue Medical Management workshop—all Venue Medical Managers (two full days).

Stadium rehearsals

All stadium staff attended an intensive on-site rehearsal programme before the first match. These were practical sessions, including unpacking and checking all clinic equipment, consumables and medications according to a standardized checklist, scenarios to practice patient workflows and communication and radio training integrated stadium orientation with the paramedic teams.

Workforce hub

Staff started and finished their work shifts at the workforce hub. The hub was in a central location in Doha and had enough parking space for all working staff, which was valuable as it was difficult to find enough parking spaces for staff close to the stadiums. Staff signed in and out at the hub, recording their actual hours worked. The hub was also used to distribute medications (including controlled medications) & radios, and to allocate drivers to ambulances. Second part passes were distributed here for use in specific zones at the official sites. There was a back-up team on standby, who could replace sick or absent members of staff at short notice. After a team debrief, staff were taken by busses to their work locations for the day. This ensured that a full complement of staff arrived each day at their venue, and they arrived on time. For stadiums this was usually at 4 hours before kick-off, which allowed everyone to be in place at 3 hours before kick-off when the gates opened. At the end of the working day, the process was reversed with staff taken back to the hub by bus, returning passes, medications & radios, and having a final debrief before returning home.

TOURNAMENT SERVICES

Competition sites

Management & support

Each stadium had a Venue Medical Manager (VMM) and two Assistant Venue Medical Managers (AVMMs). The VMM was a physician and had overall responsibility for medical services within the stadium, but with a specific focus on assisting the FIFA Medical Coordinator with player care. The VMM facilitated and supported decisions regarding player care & transport. One of the AVMMs (Medical) was a physician and responsible for all spectator, workforce and VIP/VVIP clinics. The other AVMM (Ambulance) at each stadium was a high-ranking ambulance paramedic and responsible for all paramedic, mobile and ambulance services in the stadium, including the coordination of arrangements for patients who needed transport to hospital. The AVMM (Ambulance) was in the Venue Operations Centre (VOC) and in direct physical contact with representatives of all the functional areas in the stadium. He had an overview of the pitch and the seating bowl, which aided his coordination role. All radio communication went through the Venue Operations Centre.

The Hamad Medical Corporation Ambulance Services is the main ambulance service provider in Qatar. They had a mobile command unit (MCU) at each stadium on match days. Communication between the VOC and MCU was supported by a communications team (2-3 dispatchers, a watch officer and admin support). HMC Ambulance Services also had an operational leadership team at each stadium, which assisted in decisions regarding hospital referral and transport and any mass casualty incidents.

The medical services at each stadium were further supported by logistical, IT and medical waste management and mechanical support staff.

Field-of-play teams

Medical services for all venues and constituent groups are important during a tournament, but from a sports medicine and FIFA perspective, player medical care is paramount. The field-of-play medical teams are the “face” of tournament medical services as they are in front of the cameras. Each match had two FoP teams, each consisting of an emergency physician and three ALS-trained paramedics. Each stadium had two ambulances situated in each of the side tunnels leading onto the pitch. They were parked facing the exit to allow for a quick exit of the stadium in case of an emergency. Each ambulance had two paramedics and one of the tunnel ambulances also had a critical care paramedic (CCP). Each of the FoP emergency physicians and the CCP carried resuscitation and controlled (usually opioid) analgesics with them. Each FoP team had an automated external defibrillator with them as well as all the necessary equipment and consumables to manage on-field emergencies. The CCP carried a manual defibrillator and more advanced emergency equipment (advanced airways, intra-osseus access, cricothyroidotomy sets, manual chest compression devices, etc.).

Player medical centre

The player medical centre was situated in the competition corridor very close to the players tunnel in each stadium. The centre staff consisted of an emergency physician and emergency nurse. According to the patient workflows agreed with FIFA Medical, any player with an on-field emergency would generally be taken straight to the player’s ambulance next to the pitch and not be taken via the centre. However, there is always the possibility of an emergency developing in the competition area or even the player medical centre. Therefore, the clinic was set up like an emergency department resuscitation room with all necessary resuscitation equipment, consumables and medications to manage most emergencies. Given that the player medical centre was used for players and referees, it was important from a patient confidentiality perspective to divert other patients to different clinics. Every player medical centre had a dedicated ambulance, which was parked close to the clinic, which would be immediately replaced should the original be needed for transfers.

VIP and VVIP clinical service

Every VIP and VVIP lounge had a dedicated clinic, staffed with an emergency physician and nurse. Each clinic was set up like an emergency department resuscitation room with all the equipment, consumables, and medications to manage most emergencies, as previously discussed. Each stadium had one or two ambulances dedicated to VIP/VVIP guests.

General clinic and ambulance

Each stadium had a general clinic, which was operational throughout the exclusive use period. This is the period from 15 days before the first kick-off until three days after the final whistle at each stadium when the stadium is under FIFA’s responsibility. The general clinic was for use by the workforce and was operational from 07:00 until 23:00 every day (including match days). It was staffed by a family physician and nurse. The clinic was also set up like an emergency department resuscitation room with all the equipment, consumables, and medications to manage most emergencies There was also an on-site ambulance with two paramedics, operational 24-hours per day throughout the exclusive use period.

Spectator medical services

Depending on the size of the stadium, each stadium had between 5 and 10 spectator clinics. Each clinic was staffed with a family physician and nurse and set up like an emergency department resuscitation room with all the equipment, consumables and medications to manage most emergencies. Table 1

Each stadium also had a tent clinic that was outside the actual stadium building, but inside the stadium perimeter. These clinics had a minimum of three beds and were set up like all other spectator clinics.

Paramedics and nursing staff were deployed as mobile medical teams in each stadium. Each team consisted of two team members and there were between 14 and 29 mobile teams per stadium (depending on the size of the stadium). The number of teams were determined using a formula of one team for roughly every 2500 spectators. The teams were spread out as foot patrols in the seating bowl, the stadium concourse and inside the stadium perimeter.

There were also teams on bicycles and golf carts around the stadium and in the Last Mile.

Each stadium had a total of eight ambulances with another four ambulances on standby at the remote search park. Ambulances could only enter the stadium if they had the correct Vehicle Access Pass and after they had been searched and sealed at the remote search park. This requirement was waived in case of an emergency, which depended on good communication between medical and security services in case of an emergency.

Mass incident response at stadia

A flat, empty space was identified next to every stadium where the ambulance services could stage their mass incident response (MIR). Two MIR trucks and a mobile command centre were parked in this area. The trucks contained all the equipment, consumables, and medications to deploy four MIR tents within 20 min: triage (blue), non-urgent (green), urgent (yellow) and critical (red). These tents essentially became a small field hospital in case of a mass casualty incident, where 90 non-urgent, 24 urgent and 18 critically injured patients could be treated. The critically injured tent was set up like a mini-intensive care unit where all 18 patients could be on ventilators running simultaneously for 8 hours.

Non-competition sites

Team Base Camp Hotels and Team Training Sites

All teams travelled with their own medical teams and therefore it was not necessary to provide a clinic at any of the Team Base Camp Hotels. However, the on-call doctors remained available for any member associations delegation) member who wished to have an in-room consultation. This was particularly useful where team physicians may have been occupied at training or matches while a delegation member remaining at the hotel required medical assistance. FIFA requires that all Team Base Camp Hotels should have an ambulance available within 5 min response time. Due to limited resources, it was not possible to have an on-site ambulance at each of the 32 Team Base Camp Hotels. However, given the proximity of many of the hotels to each other, it was possible to fulfil the response time criteria by using an ambulance cluster system. Hamad Medical Corporation Ambulance Services carefully mapped distances and calculated driving durations between hotels, placing their ambulances at locations where each of the hotels in a cluster (between two and four per cluster) could be reached within 5 min.

As per FIFA requirements, dedicated ambulances with two paramedics each were on site 30 min before each training session and stayed for its entire duration at every training site.

Referees’ hotel and training site/Referees’ Cup

The referees travelled with their own medical team, including physicians and physiotherapists. We therefore did not have a clinic at the referees’ hotel. The medical services at the referee hotel replicated the services available at the Team Base Camps. The Referees’ Cup was an additional tournament which was held from 10 – 25 Nov and involved the FWC2022 referees and teams from a local league. Matches were played every day, but they were in the same location as the referees’ training. We therefore did not provide additional medical services, utilizing the existing on-site ambulance for any emergencies.

International Broadcast and Media

The International Broadcast Centre and Main Media Centre were hosted in one building, the Qatar National Convention Centre. Each entity occupied half of the building and had different operational times and medical needs. Each had a variety of phases, which also resulted in different medical needs. Several broadcast and media studios were constructed inside the building. During the set-up, installation and dismantling phases of these studios, there was a greater risk of workers sustaining trauma, and therefore an ambulance with roaming paramedics were provided. During the operational period, there were more than 12,000 journalists and workforce present in the building, which required the services of a family physician and nurse in a well-equipped clinic, in addition to the on-site ambulance with paramedics. 

There was an additional location for international media close to Souq Waqif in Doha. The Outside Presentation Facilities were studios constructed close to the traditional souq in Qatar and on the Corniche waterfront. An on-site ambulance and paramedics were provided during set-up, installation and dismantling phases and an on-site clinic with family physician and nurse during the operational phase.

FIFA hotels and accommodation

Since the entire tournament was staged in one city, there were two FIFA VIP/VVIP hotels throughout the tournament, an additional four FIFA VIP/VVIP hotels during the opening and closing matches and four different FIFA workforce accommodation hotels and compounds. These were covered by on-site clinics with family physicians and nurses at the two main FIFA VIP/VVIP hotels as well as the two largest FIFA accommodation sites, and an on-call doctor service for the remaining hotels and accommodation sites as well as ambulance cover via the cluster system. The cluster system allowed for a more efficient utilization of resources, while preserving the 5-min response time.

Tournament Headquarters

The Tournament Headquarters was in the Doha Exhibition Centre, together with the FIFA Offices, Host Country Main Operations Centre, accreditation centre and uniform distribution centre. There was an on-site clinic with a family physician and nurse as well as on-site ambulance with two paramedics. This clinic was used by staff and workforce who were based at the DEC and was particularly useful to those FIFA staff who stayed in FIFA accommodation where there was no on-site clinic.

MEDICAL COMMAND CENTRE

The MCC located within the National Healthcare Incident Command Center was the central communication and coordination centre for all medical services for the FWC2022 in Doha, Qatar.  It aimed to coordinate the provision of the best access to healthcare for the FWC2022 event in collaboration with different stakeholders.

The key outputs from the MCC were an integrated, multi-agency referral system for clinical specialties, centralized tracking of medical cases from assessment until discharge, real-time/ proper notification, and timely reporting of incidents by daily/weekly/consolidated reports.

Medical Command Centre Role

The Medical Command Centre supported the various services provided, such as the clinics, ambulances, and mobile patrol teams at all event sites, which included all hotels, stadiums, Fan Festival, Fan Zones, media centres, training sites, ports of entry, and coordination centres. This also included coordinating and supporting all healthcare facilities in managing FIFA visitors, VIPs, delegates, teams, workforce, etc., ensuring they received the appropriate care in a timely manner.

The MCC worked closely with multiple departments and organizations to enable efficient and effective services to be provided, as per the FIFA Medical Handbook. Hamad Medical Corporation provided the permanent staff to fill the roles named in the next section as well as being the primary provider of healthcare for the tournament for FIFA as well as the general visitors.

Aspetar Orthopaedic and Sports Medicine Hospital worked closely with the Medical Command Centre to take incoming calls and manage players’ care in their specialized facility, and provided sports medicine and orthopaedic services exclusively for the participating teams. The MCC also worked in coordination with the Home Health Care Service, a service provided by HMC to supply a team of physicians based in the MCC 24/7 to respond to non-urgent requests for medical advice and care from all FIFA assigned hotels and other sites as required. Within the MCC, there was also a representative from the Primary Health Care Corporation, whose main role was to coordinate any issues regarding its centres.

The Medical Command Centre had a very close relationship with the Qatar Ministry of Public Health (MOPH). The MOPH were responsible for providing information and advice on public health issues, including Environmental Health, Infection Control, Food Safety divisions, and communicable disease surveillance. In addition, they provided a link to private sector health care support when required. The MOPH, the World Health Organisation and FIFA collaborated closely to provide timely information regarding the COVID-19 pandemic and instituted a COVID-19 protocol for the tournament.

The MCC further collaborated closely with Hamad Medical Corporation Health Information and Communications Technology who provided technical IT support to the MCC, including all Cerner and the Ambulance Service Reporting (ASR-NAS) application related issues, and FIFA Medical to understand services required by the various categories of people of interest, e.g. players, FIFA Executives, FIFA workforce and VIPs. This enabled the creation processes to manage each patient type to meet the FIFA standards and expectations. 

The MCC worked within a “hub and spoke” model. They were the epicentre of organisation and information exchange. With regards to information exchange and trend analysis, the MCC  were tasked with producing dashboards on all clinical activity being carried out in the event sites. This was done by collating the data from various medical information systems such as Cerner and the ASR-NAS, which was a bespoke application created for the tournament. The data was collated into a data warehouse, which then provided the feed into the dashboards.

There was also real-time tracking of patients transferred from event sites to the hospital until their discharge, where identifying patient data was communicated separately from the clinical information through secure chat groups in real time. These patients were split into three groups: Group 1 was the Players and VIPs, Group 2 was FIFA Workforce and Media, and Group 3 was everyone else coming from an event site.

FIG 8, 9, 10

EMERGENCY CARE SERVICES

Emergency care services in place for the FWC 2022 were the product of four main components, namely:

1.        National Ambulance Service operated by HMC

2.        HMC network of hospital-based emergency departments across the country

3.        Special Medical Sector Major Incident Preparedness and Resilience arrangements

4.        Coordinated planning and use of a robust Command, Control, Coordination and Communication (4C) structure

1. National Ambulance Service

The existing National Ambulance Service response system operated by the Hamad Medical Corporation Ambulance Service, with additional support from the Qatar Red Crescent and Qatar Armed Forces, played a central role in the provision of emergency ambulance care services during the FWC2022. All frontline Emergency Ambulances in Qatar are equipped with Advanced Life Support (ALS) equipment and supplies, including the ability to transmit 12-lead ECGs and cater for automated external chest compression. These first response frontline ambulances are staffed by ALS-trained and qualified Ambulance Paramedics (APs) who in turn are supported by specialised Critical Care Paramedic (CCP) units. These CCP units are dispatched in support of any ambulance crew requesting assistance, as well as being included in the primary dispatch to all potentially life-threatened cases.

In the rural areas of Qatar, this CCP support is further supplemented by the rotary wing aeromedical service ‘LifeFlight’, providing additional CCP capacity and rapid specialised transport back to a tertiary care facility from remote areas. This critical care aeromedical service proved particularly effective when dealing with critically ill or injured patients in the soft sand desert locations, primarily situated in the south of the country. Large dune, soft sand desert areas prove challenging for ground-based resources to adequately service. These areas are however a major attraction for high-risk touristic and recreational activities, including the use of quad bikes and other motor and water sports. This combination of high-risk activity and remote location access, makes serving the emergency care needs in this area challenging. In consultation with local authorities, the regular use of these areas for camping during the FWC2022 was restricted. This provided a welcome reduction in the amount of business-as-usual emergency calls in the area. In turn, this helped to ensure the increase in touristic recreational activity related emergency calls could be well served.

A further ambulance resource widely used during the FWC2022, in areas where vehicle access was not possible, were mobile medical teams. Such teams are routinely deployed in large parks and pedestrian zones as well as within the large indoor footprint of Hamad International Airport terminal. Mobile medical teams are deployed in a variety of forms including teams on foot, bicycle teams and teams using golf carts. Working as a system, these mobile teams allow for rapid first-response provision followed up by ALS and subsequently CCP capacity. The use of different transport modalities allows for rapid transport from any pedestrianised areas to a waiting regular emergency ambulance for onward evacuation to hospital as required. Additional use of these teams in and around stadia and other fan activation zones was a central component of our emergency medical services for the tournament overall.

In order to appropriately prioritise response to emergency cases, all requests for emergency medical service are telephone-triaged by qualified and licensed Emergency Medical Dispatchers (EMDs), who make use of internationally recognised priority dispatch protocols. When ambulance service resources are dispatched, this is done in consort with other uniform emergency services using a unified national dispatch system. The result of this approach is the concurrent dispatch of all required resources in support of a medical emergency call. In addition, these EMDs will provide often lifesaving, pre-arrival instructions to the caller. These include step-by-step directions on interventions such as CPR or the Heimlich manoeuvre. As such, the use of pre-arrival instructions contributes directly to the effectiveness of care within the emergency medical system.

2. Hospital-based emergency departments

The second essential element in the system of emergency care during the FWC2022 was the regular emergency department infrastructure associated with, each of the five Hamad Medical Corporation General Hospitals:

1. The Adult Tertiary Emergency Department and Level 1 Trauma facility at Hamad General Hospital
2. Sidra as tertiary paediatric trauma centre
3. HMC’s network of Paediatric Emergency Medical Centres
4. The Heart Hospital for Cardiac Care
5. The Woman’s Wellness and Research Centre for Obstetric and Gynaecological Emergency services.

Onward emergency referral for additional specialised care such as mental health services or support in the case of sexual assault, was facilitated in one of the primary receiving facilities listed above or via a prioritised transfer process as required.

In an effort to reduce the load on emergency departments, ensuring they would be available to deal with any emergency cases that may present to them, three specific strategies where applied. The first of these involved the active promotion of the country’s extensive Primary Health Care Centre infrastructure for use by the resident population. The second involved the creation of an extensive temporary clinic capacity across competition and non-competition facilities – where, in key locations, senior emergency medicine staff were used to provide effective on-site emergency and urgent care. The third involved signposting visitors where appropriate to make use of the well-established and resourced private healthcare sector in Qatar. This signposting was achieved primarily by directing those seeking how to access healthcare services to the Ministry of Public Health’s specially developed FWC2022 fan information website https://sportandhealth.moph.gov.qa/EN/faninfo/Pages/Homepage.aspx. This site provided a wide range of health information along with where and how best to access care based on the nature of their medical needs. In some cases, this meant directing people to help lines rather than seeking in person care.

3. Medical sector Major Incident Preparedness and Resilience arrangements

Existing, well-established, tried and tested Major Incident Preparedness and Resilience arrangements were strategically bolstered during the FWC2022. This increase in preparedness to respond was arranged in line with risk assessments incorporating intelligence gleaned from partner security agencies and others. In addition to links between existing command and control arrangements and specially created FWC2022 structures (discussed in more detail in the next section), our planning identified the need for the strategic placement of additional major incident resources across the country.

With due consideration for where and when different areas would have mass gatherings, as well as incorporating the security risk profile of different locations, specific sites were identified for allocation of staged resources to support responding to any major incident. These strategic deployments included:

• Major Incident Mass Casualty Treatment Pods at all active stadia and other mass gathering locations
• Mass Haemorrhage kits deployed across all active site in both competition and non-competition locations
• Tactical Response teams at major unsecured mass gathering sites

Importantly, as much as the strategic deployment of resources was key to our Major Incident Planning, so too was the extensive Major Incident training incorporated into both on-site as well as hospital-based medical staff. This training focused on ensuring those working on site would know exactly how to interface with the out of hospital major incident systems in place, ensuring their clinical capacities could be best used. Other hospital-based training focused on improving the Emergency Department’s ability to manage large numbers of self-presenting casualties alongside those being brought into hospital by ambulance.

Using the 4C structure (discussed next), the provision of resources along with the training of staff was seen as an essential combination to ensure the best possible response to any potential major incident could be achieved. While we thankfully did not have any major incidents during the event, we were confident that testing during pre-event exercises did illustrate that robust plans were in place. Furthermore, the collaborative working fostered by the major incident plans and preparations certainly supported the required unified approach seen during the management of isolated serious cases experienced during the FWC2022.

4. Command, Control, Coordination & Communication—4C

To appropriately effect the provision and deployment of such an extensive emergency medical service infrastructure and system required detailed planning and the implementation of a robust command, control, coordination & communication (so called 4C) structure.

Coordinated planning

In support of the many organisations who had been working for some time on planning for and preparation of medical services required for the FWC2022, a Ministerial Decree on ‘Establishing and forming the Health Strategic Committee for the 2022 FIFA World Cup’ was developed in 2020. This Decree paved the way for the formal establishment of a Strategic Command Group and associated Tactical Command Group structure under the auspices of the Minster of Public Health. This arrangement provided the necessary overarching governance framework to facilitate high level decision making and the securing of much needed allocation of funding in coordination with that already budgeted for by the Supreme Committee for Delivery and Legacy.

Importantly, this command group structure also provided clarity on the commissioning versus operational delivery of health sector-sponsored services. The governance structure included the ‘FIFA World Cup 2022 Health Strategic Command Group’ with senior representation of the SCDL, into which a series of tactical level groups reported, covering the domains of tertiary care, primary care, public health service delivery and Major Incident Preparedness and Resilience. In addition, the Health Strategic Command Group was further supported by Scientific Reference and Research, as well as policy, planning and performance teams. The chairperson of the existing Covid-19 National Health Strategic Command Group was also a member of the command group and as such provided the required link with Covid-19 pandemic considerations.

The overarching objective of the planning governed by this structure was to provide the best possible healthcare services to the tournament constituents, including participants and spectators without adversely affecting the services provided to the local resident population. In doing this, the goal was to ensure the meeting of all FIFA requirements, as issued by the SCDL, while maintaining the readiness of the health sector to respond to the Covid-19 pandemic or any other major incidents, without affecting Qatar's commitment to hosting the tournament and delivery of business-as-usual healthcare services.

4C structure establishment and use

A key tactical outworking of the planning governed by the structure above was the establishment and testing of a robust 4C structure. The goal of this structure was to ensure coordinated running of day-to-day operations up to, during and after the tournament throughout the so called ‘FIFA exclusive period’. This 4C structure made extensive use of business-as-usual components and was tested and tweaked as required following experience of its use in the multiple large scale sporting events hosted by Qatar over the years. A final version of the 4C structure to be used for the World Cup was tested and validated during the FIFA Arab Cup Qatar 2021™ hosted by Qatar at the end of 2021.

Key elements established to support this specific World Cup 4C structure included:

• Workforce and logistics hubs facilitating the coordinated deployment and use of both workforce and all non-human resources
• A network of Venue Operations Centres (VOCs) and mobile control centres positioned at the largest event locations including all active stadia
• Temporary reporting arrangements into a medical cell established in the Tournament Command Centre (TCC) hosted in the National Command Centre (NCC) building
• Establishing an MCC hosted in the National Healthcare Incident Command Centre (NHICC) building
• Use of parallel reporting lines from the MCC to the FWC2022’s Host Country Main Operations Centre and the FIFA Tournament Headquarters.

The physical location of the MCC and TCC within existing national emergency management infrastructure (in this case the NHICC & the NCC) was central to leveraging planned linkage between tournament and business-as-usual operations, including standing Major Incident Management plans. This means that the whole Emergency Medical Services system was in a heightened state of readiness throughout the FWC2022 period.

ASPETAR PARTICIPATING MEMBER ASSOCIATION TEAM SERVICES

“What do I need when I travel to a Football World Cup as a team physician?” This question is  the basis of any needs analysis for organizing athlete medical services for such events. When the FWC2022 was awarded to Qatar in 2010, a unique opportunity presented: To help the participating team medical staff and to provide medical services to athletes out of one hand. In contrast to all previous FWCs, the FWC2022 essentially took place in one city, which made medical service provision for athletes much easier, as services did not have to be replicated in each of the cities of the host country hosting matches.

Thus, instead of focusing on providing standardized basic care in different locations and cities, it was possible to analyze the specific needs outlined in the opening question in detail. For this purpose, a group of experts (of which the authors were part) were assembled to learn from their years of experience. This included a World Cup competitor and both team medical staff at major sports events such as World Championships in various sports and Olympic Games and the organizers of athlete medical care at such events. Thereafter, this group was refined and tasked by the highest authority with organizing athlete medical care at the FWC2022.

It was clear from the outset that the individual needs of the participating teams would be very different, given that the 32 participating teams come from different countries and have different medical resources at their disposal. Well-organised teams travel with many specialized medical staff and considerably advanced (diagnostic) equipment, whereas other teams just have basic medical support, consisting of a doctor and physiotherapists and massage therapists. In the lead up to the competition, teams were therefore contacted through FIFA Medical to investigate the situation of each team and identify individual needs in order to provide all participants with equal opportunities. This was followed up with site visits and individual feedback during the Team Doctor Workshop a few months prior to the tournament, which also enabled the participants to communicate the individual needs of their teams.

The feedback from this needs analysis of the teams, individual experiences from the organizing expert group and requirements from the governing bodies led to the identification of several key areas. These directed the service concept that was at the basis of the player medical care for the FWC2022.

Privacy and Confidentiality

One of the key points repeatedly fed back from teams during the needs analysis were concerns about privacy and confidentiality. Teams did not want the public or other teams to know that a player was injured or undergoing investigations to exclude more serious injuries. This is understandable, as the information about injuries (or suspected injury) of key players can open new tactical options for opposing teams. It was thus clear that specific measures to guarantee this request had to be taken.

Easy access to medical services

For team physicians travelling with their teams to other countries, it is often difficult to smoothly access medical services, such as imaging or medication, due to them lacking the medical license for the country and policies of hospitals. The latter often only allowing medical imaging or medication dispensing after review of the patient by a resident physician. This was another area that would need improvement for the tournament. This also included the fast and easy communication of any requests and access to the results of investigations.

Availability of equipment and support staff

Equipment transport is cumbersome, and many teams lack medical staff at competition due to various reasons (financial, accreditation etc.). Therefore, being able to borrow certain types of equipment or get expert staff to support the team during the tournament was another service that was frequently requested.

Additional services - Recovery

Recovery services was one area of potential benefit for many teams identified by the expert group. Efforts to improve recovery activities are often neglected during tournaments where teams stay in hotels and do not have access to the same recovery facilities compared to their home settings. There is also a large potential gap between well-funded teams that can bring recovery equipment with them and stay in hotels with adequate spa facilities that can be repurposed and other teams, who will not have such resources at their disposal.

The action plan

From this information, three key projects were created to cover the identified needs:

1. Team services: The aim was to improve medical care for teams by supplying medical equipment and additional medical staff upon request. The team service staff had a vast experience in event medical care, covering many international sporting events in the country over the years. They also provide medical services to all Qatari National teams (all sports) and teams of the Qatar Stars League and are thus well experienced and equipped in view of the requirements of elite football.

2. Polyclinic: Aspetar Orthopaedic & Sports Medicine hospital was the dedicated polyclinic for the tournament. In view of the privacy and confidentiality requirements highlighted above, parts of the hospital were made not accessible to the general public for the duration of the tournament and normal services to the general public were therefore scaled down. The hospital has specialists and facilities in the areas of sports medicine, orthopaedic surgery, physiotherapy, general surgery, dentistry, general practice, family medicine, emergency medicine, internal medicine, cardiology, anaesthesia, radiology, pharmacy, podiatry, exercise physiology and laboratory medicine. A 24h-schedule for most of the services was established for the tournament. At the specific request of FIFA Medical, specialised Sports Cardiology and Sports Concussion services were integrated into the polyclinic.

3. Recovery centre: As of the needs analysis above, a dedicated facility (“recovery centre”) was created within the Polyclinic. The centre consisted of a pool (water temperature 31 °C) to conduct recovery exercise activities in the water, contemporary contrast spa baths (hot at 35 °C and cold at 9 °C), massage cubicles for massage therapists, a stretching and mobilisation area with access to various vibration devices (foam rollers, massage guns, massage balls), a rest area with compression pulse therapy, spin bikes and a recovery sports nutrition station.

In the lead up to the tournament, FIFA Medical also highlighted the importance of a central request system, i.e. all team requests should be channeled through one central entity (the MCC), see above), which would then forward the requests to the appropriate receiver. The athlete part of the MCC was staffed by nursing staff experienced in sports medicine and event matters.

The event

The abovementioned three key services were operational at different times: FIFA and Q22 Team Services had started several months before the tournament to gather and service the different requests.

The most active period was before the start of the tournament when 17 teams were supplied with a total of 67 additional pieces of medical equipment, mostly physiotherapy beds. With the ongoing tournament, consumables (e.g. bandages, medications, supplements) were the most requested items. From a human resources side, 52 medical staff were seconded to provide health-related services to six teams, the match officials and two ancillary tournaments involving fans and VIPs related to the event. In total, the seconded staff provided approximately 2500h of medical services.

The polyclinic was fully operational as a 24h service 10 days before the tournament. Despite the fact that it could be assumed that all teams would arrive at the competition well prepared and without injuries, the polyclinic was in demand from the beginning. The number of medical services provided per day is illustrated in Figure 13.

The busiest period was the second part of the group phase, which is in line with previous reports about the occurrence of injuries and illnesses during such tournaments. Another peak is visible towards the end of the tournament (15.–16. December). This because of a separate tournament involving former players and VIPs unrelated to the FWC2022 itself that generated a number of severe injuries. Overall, the department most in demand was radiology/medical imaging (Figure 12). The number of imaging requests per modality is shown in table 1. As can be expected from the typical injury profile in football, MRI was the modality most in demand (hamstring injuries are usually the most common injury in football). Interestingly, podiatry was the second most requested service. fig 12 TBL 2

The additional services (concussion, sports cardiology) were in variable demand. Only one suspected concussion case was assessed, and the team doctor was assisted with clear recommendations regarding the management and return to play.        

The sports cardiology service saw eight athletes and assisted external health care providers with expertise in another three cases. The recovery services were used by three teams in total throughout the tournament. Water-based recovery activities (pool, hot-cool baths) were the most used facilities. The sports nutrition section dispensed over 800 nutritional recovery items.

In retrospect

Looking back, the most important take away points to provide successful athlete medical care at a tournament of the size of the FWC2022 are preparedness and flexibility.

“Preparedness” was achieved at different levels: The facility used to provide the athlete medical services (Aspetar Orthopaedic and Sports Medicine Hospital) had a 10-year+ track record of event medical care at the highest level, having helped all major sports events in the country in the last decade. A large number of its staff had previously worked in different functions at both team and organizer level in elite sports. Thus, both the facilities and the staff were already well prepared of what was to be expected for an event such as the FWC2022.

Preparedness also applies to internal processes. The key here was not to change existing processes, but to refine and update to reflect a quick decision capability where needed. Implementing new processes for a high profile event without sufficient training or a trial run is a recipe for failure. This was approached in two ways: In the year prior to the main event, a trial event held during the same dates as the FWC2022 (FIFA Arab Cup 2021) allowed to test existing processes and identify gaps. Based on the findings and amalgamating the needs analysis above, internal processes were then optimized and tested in the lead up phase to the tournament, when normal clinical activities in the hospital were reduced for this purpose. Especially the last part proved to be extremely beneficial as several issues were identified that were unaccounted for in any previous event or planning, such as, for example, a change in cybersecurity settings for all governmental organizations of the country for the FWC2022, which required important adaptations in the implemented medical communication systems at short notice.

It was clear from the beginning that the playing field at a FWC with multiple participants and stakeholders at different levels would be impossible to manage without flexibility. Thus, for most processes, alternative and substitute action plans were in place. As an example visible in the data presented above, there were two additional tournaments for fans and VIPs, ancillary to the FWC2022, that needed additional medical coverage (doctors, physiotherapists, equipment). Due to a preemptive planning for such VIP requests, which had already occurred at previous events, resources (“special ops”) were set aside from the start and thus prevented any disruption of routine services.

Perspective for the future

While it is unlikely that any football competition such as the FWC2022 will be held in one city only in the near future, it is possible that this concept will be adapted for smaller tournaments, such as Youth World Cups or Championships. The data shown here provide a broad overview of the requirements to cater for similar events, which might be helpful for future organizers. At the same time, it also outlines for the first time what services sports medicine service providers can expect of having to deliver during a major football tournament.

Acknowledgement:

The authors would like to sincerely thank Dr Ahmed Al Mohammed, as Chair, along with all members of the FIFA World Cup 2022 Health Strategic Command Group and associated Tactical Command Groups; Dr Abulwahab Almusleh, FWCQ22 Chief Medical Officer Q22, for his leadership and expertise; Julia Gibson, Medical Operations Director SCDL; Sabrina Jamal,  Medical Coordinator Q22; Dr Bassam Qambar, Dr Hamed Gharib, Dr Sameer Abdurahiman, Mr Ridha Miladi, Mr Saleh Al Meqareh, Mr Shabbir Pokkakillath, Dr Muna Almusleh, Dr Khalid Alkhulaifi, Dr Omar Al-Seyrafi, Dr Celeste Geertsema and all field-of-play medical teams; all Venue Medical Managers and Deputy Venue Medical Managers; all MCC staff; all doctors, nurses and paramedics along with support staff working in the clinics, ambulances and mobile patrol teams across different event sites; all ambulance drivers; Dr Louis Holtzhausen, Chief of Sports Medicine, Aspetar; Dr Guido Pieles, Head of Sports Cardiology, Aspetar; all HMC and Aspetar staff; Gordon Penney, Hisham Abi Ammar and their team; and all staff at the different healthcare facilities supporting the World Cup effort.

Our special thanks go to the team doctors of the 32 participating teams for their collaboration and input that helped us shape and improve the services.

Katharina Grimm MD

FIFA Medical Lead

Abdulahad Denha T

Liesel Geertsema MD

Sports Medicine Physician

Aidan Jones

Daniel Kings PhD

Brendon Morris

Yorck Olaf Schumacher MD

Sports Medicine Physician and Head of Sub-specialty medicine

Andrew Massey MB BCh BAO MSc(Sports Medicine) MSc(Medical Ultrasound) MSc(Sports Physiotherapy) BSc(Hons)(Physiotherapy) MRCGP FFSEM(UK) FFSEM(Ire) FFMLM

FIFA Medical Director

Chair FIFA Medical Committee

Zurich, Switzerland

Contact: katharina.grimm@fifa.org

Header Image by Ronnie Macdonald (Cropped)