Introduction

The Asian Games, organized by the Olympic Council of Asia (OCA), is the largest sports competition in Asia, held once every 4 years1. In 2022, as the COVID-19 pandemic created widespread disruption to global sporting events, the OCA decided to postpone the 19th Asian Games for 1 year2. The high-profile 19th Asian Games was finally held from 23 September to 8 October 2023, in Hangzhou, China, attended in-person by 45 National Olympic Committees (NOC), 11,830 athletes, and 5711 team officials. About 5000 media reporters, 5500 broadcasters, 3,000,000 spectators, and 80,000 staff also participated and witnessed the sports event.

The 19th Asian Games was held across 56 competition venues, 31 independent training venues, and 31 non-competition venues prepared by the host city, Hangzhou, and five co-host cities: Ningbo, Wenzhou, Huzhou, Shaoxing, and Jinhua, which were around 2 h drive from the host city. From the medical perspective, the organizing committee faced challenges in the transition from closed-loop to opened events. Large-scale sporting events in the post-pandemic era face unprecedented medical challenges, including fragmented health resource coordination across multi-venue settings, dynamic public health risk mitigation, and balancing routine care with pandemic protocols. Notably, Arbon et al. identified staff interoperability as a critical gap in mass gatherings, while the WHO Guidelines emphasized real-time syndromic surveillance for outbreak control. Recent studies further highlight systemic inefficiencies: Engebretsen et al. reported inconsistent injury documentation at mega-events delaying triage, and Gallego et al. demonstrated that hybrid healthcare models (e.g., telemedicine + onsite care) reduced hospitalization needs by 32%. The risks and characteristics of post-pandemic large-scale crowd gathering activities and injuries/illnesses caused by large-scale sporting events have served as a stress test for the Medical Command Centre (MCC) of the Hangzhou Asian Games Organizing Committee (HAGOC)3,4,5,6. To provide rapid medical responses, MCC sought to implement intelligent technology to monitor infectious diseases and other medical cases, and control any possible outbreaks. The MCC fully considered different aspects of medical services and finally presented the construction of a consummate medical security system7.

This study aimed to elaborate on the preparation and overall design of the 19th Asian Games from the medical perspective. We expect our findings to provide baseline references to future organizing committees for constructing effective and efficient medical support systems for large-scale sporting events. The medical information system can be used to suggest the rational distribution of medical support personnel and medications to meet the prerequisites demanded by various groups during the Games. The method of reasonable partition in the designated hospitals may give insight to future organizing committees on raising the efficiency of emergency transfers and maintaining the daily medical services7. Generally, we outlined how the medical security system assisted in the successful completion of the Asian Games, which is the study’s key contribution to the field.

Methods

The study is a descriptive epidemiological survey of healthcare utilization during a mass sporting event, this cross-sectional study analyzed medical services during the 19th Asian Games (September 23–October 8, 2023). Patients and the public were not involved in the design, or conduct, or reporting, or dissemination plans of the study. Personnel trained via standardized modules (WHO Mass Gathering Guidelines) across co-host cities.

Scope of medical services

To provide maximum medical coverage for the 19th Asian Games, the MCC set up a high-level, full-spectrum medical care system. A total of 163 medical rooms, 96 Field of Play (FOP) medical stations, 83 medical stations for spectators, and 1886 medical support staff were setup across the competition, independent training, and non-competition venues. For emergency transfers, 129 ambulances were deployed to provide medical support, and one to two ambulances were set up at each venue, considering the size of the field, number of competitions, and type of events. Moreover, the host cities designated 40 hospitals and 33 referral hospitals to provide comprehensive medical services. Medical services were provided for all participants from the pre-opening (9 September 2023) to the closing (11 October 2023) of the Asian Games Village.

Medical command centre

The MCC was responsible for the overall command of medical-related encounters during the 33-day period of the 19th Asian Games. Staff members were elite members selected from different hospitals, city and provincial health missions, and the Bureau for Disease Control and Prevention. The team received medical guidance from national medical specialists from clinical departments.

Public health protocols

To prevent any COVID-19 outbreak, the Games implemented regular epidemic control for all incoming participants. The HAGOC recommended all participants to have complete the COVID-19 vaccination before entry to China, prioritizing self-protection. During the games, COVID-19 tests were available but not mandatory. HAGOC classified and treated all COVID-19 cases based on their severity. For asymptomatic and mild cases, the HAGOC suggested self-rehabilitation, whereas for medium or severely infected personnel, the HAGOC provided medical services at designated hospitals.

Medical information systems

To precisely record and collect all medical encounters, the MCC used two intelligent medical information systems, namely, EMSS and AGIS-MED. According to OCA guidelines, the AGIS-MED was installed in all medical rooms at venues to track patients’ diagnoses. The EMSS was developed especially for the 19th Asian Games, to provide the platform for medical support staff to fill in patients’ information easily and efficiently on daily treatments with the Yayun Ding Application on their mobile phone. For emergency transfers, the EMSS made the process proceed smoothly—staff could scan the transfer Quick Response (QR) code. The medical information systems facilitated the follow-up for any medical encounter for better medical services. Moreover, the medical support staff at the venues could access the AGIS-MED using the dedicated computer and easily retrieve diagnostic and treatment information for all visiting patients. The information between the two systems was inter-commutable.

Medical services at venues

Every venue was equipped with medical resources according to the relevant tasks. The basic medical configuration for each competition venue was as follows: one medical room (one doctor and one nurse), one FOP medical station (one doctor and one nurse), and one medical station for spectators (one doctor and one nurse). All accredited personnel and ticket holders had access to basic medical, first-aid, and patient referral services. The service operation was from one hour before the start of competition up to when all athletes and spectators left the venue. For each independent training and non-competition venue, including the Main Media Centre, OCA family hotels, and exit and departure ports, MCC set up one medical room and provided 24-h medical services. Considering the particularity of specific sports and the requirement from technical officials and referees, MCC dynamically changed the medical resources allocation.

The medical resources at all venues, including medical support staff, medications, medical equipment, and other consumables, were sourced from corresponding designated hospitals based on the allocation list provided by the MCC.

Asian games village polyclinic

The MCC built a full-scale outpatient Polyclinic inside the Asian Games Village. The Polyclinic is a three-floor building housing 11 clinical departments (emergency and internal medicine, emergency surgery, orthopaedics, ear, nose and throat, ophthalmology, stomatology, gynaecology, dermatology, psychology, Chinese massage, and rehabilitation medicine) and five medical technology departments (ultrasonography, electrocardiogram room, radiology, clinical laboratory, and pharmacy). The Polyclinic operated from 15 September to 12 October and provided 24-h first aid services and 16-h (7:00–23:00) routine medical services for all patients. Chun’an Sub village also established a Polyclinic with a similar setup.

Designated hospitals

After on-site medical treatment in the venue medical rooms or Polyclinic, patients needing further treatment were transferred to the Asian Games designated hospitals. The 40 designated hospitals were determined according to the principle of regional proximity. Each venue had a corresponding designated hospital. Emergency transfers from the venues to the designated hospitals took less than 10 min. For severe cases, five hospitals were designated for infectious diseases; six, for bio-terrorist attacks, nuclear and radiation damage, chemical poisoning, widespread burns, and gunshot injuries; and four air medical emergency rescue support. According to the discipline construction of designated hospitals, 19 designated hospitals had two-way referral for major specialties, for which transfer mechanism was established.

Focusing on the privacy and confidentiality for all patients undergoing medical care, the designated hospitals were required to set up relatively independent treatment areas for all Games’ attendees, including outpatient departments, emergency departments, operation rooms, inpatient wards, and the green channel for the timely treatment and high-quality medical services for all stakeholders. This segregation also minimized the impacts of the Games on the normal medical operation of the designated hospitals.

Medical support staff

Medical support staff were selected from corresponding designated hospitals for medical monitoring at all venues. In the Rio de Janeiro 2016 Olympic Summer Games, among all medical incidences, 63% and 37% were injury and illness cases, respectively3. Considering the characteristics of large-scale sporting events and the occurrence probability of traumatic conditions, the MCC mainly selected doctors from the emergency, orthopaedics, cardiology, and surgery disciplines. The additional criterion for the selection of medical support staff was professionalism. In case of any unforeseen circumstances, the MCC reserved additional 30% medical support staff.

Medication distribution

Pharmacy services and medication administration at large multi-sports events support safe and effective medication usage8. To achieve the effective and secure dispensing of medications to athletes and other stakeholders, the MCC developed the list of medications for the Polyclinic pharmacy, according to the rules of the World Anti-Doping Agency (WADA) and List of Prohibited Substances and Methods9,10. The list included the medicine name, dosage form and dosage, administration route, and WADA status. A total of 175 medications in 21 categories were included in the list (Supplementary Table). The safe storage and distribution of medications was emphasized in the 19th Asian Games pharmacy services; each venue was assigned dedicated personnel. Athletes needed to sign a consent form before the dispensing doctor and pharmacist could prescribe any medication.

Emergency transfer

For severely ill persons, the MCC provided ground and air emergency transportation. A total of 129 ambulances provided all-around first-aid support, with each venue having one to two ambulance units (one doctor, nurse, and driver each). Considering the possibility of ambulance shortage at certain venues owing to the intensive and concentrated competition schedule, the MCC set up a certain number of regional ambulances to actively cooperate with venue ambulance replenishment and other medical transfer-related tasks and effectively deal with any major public emergency. In accordance with the principle of ensuring top quality emergency support, three medical helicopters were arranged at Chun’an Competition Zone, Tonglu Equestrian Centre, and Ningbo Xiangshan Sailing Centre to provide on-call helicopter rescue services.

Data analysis

Our data analysis included the number and categories of medical staff, medical encounters, and medication usage. The evolution in the total number of medical support staff was summarised by category and functional area. number (%) was used for categorical variables, followed by χ2 test for comparison.

Medical encounters

All medical encounters at the venues were recorded by medical support staff on the EMSS and AGIS-MED. Our study analyzed the medical encounters by date, type of venue, and accreditation category (e.g. athletes, team officials, OCA family members and international dignitaries, technical officials, news personnel, spectators, HAGOC staff, volunteers). Given that severe transfer cases need to be hospitalized, we further sorted the data based on type of illness, injury, and personnel category. For athletes’ medical encounters and transfers, we further analyzed them by sports category.

Medication usage

All medication usage were recorded by EMSS and AGIS-MED. We classified medication used outside of the established list for the Polyclinic into external use medication, Chinese patent drugs, and other drugs.

Results

Medical support staff and general distribution of medical encounters

Table 1 lists the details on the medical support staff, including their sub-specialties. Concerning medical encounters, Fig. 1 shows the distribution of the 11,658 medical encounters reported within the 33 days of medical services provided for the 19th Asian Games. The total number of medical encounters reached a peak on Day 19. For athletes, the highest number of medical encounters was on Day 17, which was the third day of competitions and had the most intensive schedule of competition.

Table 1 Numbers of registered medical support staff.
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Fig. 1
figure 1

Daily distribution of medical encounters. Dotted line, athletes; Grey line, non-athletes; Black line, total number.

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When analyzing the causes for medical encounters, we found that among the 11,658 cases, 2,368 were injuries (20.3%) and 9290 were illnesses (79.7%). The classification of accredited personnel by disease category is shown in Tables 2 and 3. The top three reasons for injury visits were skin and soft tissue contusion, joint injury, and ligament injury. For all illness visits, the top three reasons were respiratory, musculoskeletal, and gastrointestinal issues. Notably, HAGOC staff formed the largest group of those providing medical attention.

Table 2 Number of medical encounters by injury and their category.
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Table 3 Number of medical encounters by illness and their category.
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Hospitalization cases

During the 19th Asian Games, 349 cases received emergency transfers to designated hospitals, and 54 patients were hospitalized (athletes, 26; non-athletes, 48; Table 4). Half of the hospitalized athletes had been injured (9 of 18 hospitalized athletes), and the other half had illnesses. For non-athletes, 80.6% of the hospitalizations had been caused by illnesses (29 of 36 cases) and 19.4%, by injuries. Among the hospitalization patients, 19 underwent surgical operation (athletes-7; non-athletes-12). The median hospital stay for athletes was three days, and for non-athletes, five days. Statistical analysis showed no significant difference between the two categories (p = 0.072).

Table 4 Number of medical encounters for inpatient by injury, illness and their category.
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Sports injuries for athletes

Among the 1870 medical encounters reported by athletes, 762 and 1108 were injury and illness cases, respectively, equivalent to an overall rate of 6.44 injuries per 100 registered athletes (Table 2). Figure 2 demonstrates the athlete injuries by sport discipline. The highest level of injuries occurred in wrestling, basketball, boxing, sepak takraw, and hockey, which shared similar trends with the 2012 London Summer Olympics11. The highest hospitalisation transfer rate was among football, hockey, boxing, baseball, and wrestling athletes. For all injury cases, we also compared the ratio of transfer and injury cases. The highest ratio was found in baseball—53.8% (7 out of 13 baseball injuries cases) needed to be transferred—followed by football (41.3%), cricket (33.3%), wushu (33.3%), and hockey (25.7%).

Fig. 2
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The athlete injuries by sports discipline, in black and transferred to referral hospitals, in grey.

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Medication usage

All the medications used followed the medication list for Polyclinics (medication list showed in supplementary data). During the games, other medications used were not on the list, such as external-use medications and Chinese patent medicines. For all medications not included in the list, we confirmed the doping status. Any medication that could not be confirmed for the presence of stimulants could not be used by athletes. External medications were used 116 times, most commonly YunNanBaiYaoQiWuJi and KouQiangKuiYangSan. Chinese patent medicines were used 540 times. The other medications used were mainly those for fever, pneumonia, and flu (Table 5).

Table 5 Medications outside the list for Asian Games Village Polyclinic.
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Discussion

Being a large-scale sporting event after the COVID-19 pandemic, the 19th Asian Games were highly anticipated and attracted the largest attendance in the history of the Games. Across one host city and five co-host cities, the MCC mobilized resources to establish a comprehensive medical and first-aid system to provide full-spectrum medical services. Our study gathered various data on the process of hosting such a large and complicated sporting event.

Research implications

High injury rates in wrestling, basketball, boxing, sepak takraw, and hockey reflect collision intensity, necessitating sport-specific prophylactic measures (e.g., pre-bout joint screenings). Regarding the injury pattern during the 19th Asian Games, we found that the overall injury rate for athletes was 6.44 injuries per 100 registered athletes, which was lower compared with the incidence in previous Olympic Games: 9.61% in Beijing in 200812, 11.18% in Vancouver in 201013, 12.88% in London in 201211, 14% in Sochi in 201414, and 9.8% in Rio in 20163. This reduction is likely multifactorial. Crucially, EMSS-enabled real-time injury tracking reduced median on-field response time. Safer surfaces in athletics venues (installed per World Athletics guidelines) and revised warm-up protocols also contributed. However, the incidence in previous games is based on self-reports by athletes and information submitted by the medical personnel of each NOC15. During the 19th Asian Games, data entry was more accurate; all medical encounters were recorded by medical support staff of the MCC, uniformly filled into the information systems. Therefore, more information- and intelligence-based techniques could be used in future sporting events16,17.

The MCC has modified its selection preference of medical personnel after the 19th Asian Games. In preparation for this game, the MCC selected medical support staff based on previous sports events, where doctors were mainly from the departments of orthopaedics, emergency, and cardiology. According to the data collected, we formulated several recommendations for the selection of medical support staff. For large competitions, more physicians are needed at the venue; the largest group of patients is the staff members, and they usually report illnesses, especially respiratory, musculoskeletal, and gastrointestinal issues. For athletes and the FOP area of the competition venues, surgeons are needed for extreme cases. Furthermore, the sports discipline should be taken into consideration when arranging medical support staff, as different sports categories will result in different types of injury or illness. Considering that the tightness of the competition schedule will influence the possibility of medical encounters, additional medical support staff should be arranged when the matches are intense.

The medication list the MCC came up with seemed sufficient and able to meet most requirements for large-scale events in summer; only a few medications outside of the list were used. We found that more external-use medications were needed, as injury cases varied among athletes. Chinese patent medicines, representing Chinese traditional medicine, were popular among the participants. However, athletes must use them with caution because their WADA status is unclear. Future organising committees should check traditional medicines for stimulants before they can be used by athletes.

The timely transfer of severe cases and treatment of injuries and illnesses can improve the probability of the recovery to a large extent. The rate of emergency transfer for the 19th Asian Games was at 3% (349 transfers of 11,658 cases), much lower than that in the Sapporo Asian Winter Games (9.3%)1. We found that the sufficient level of medical services provided onsite and the designation of experienced and professional medical support staff largely reduced the rate of transfers. Additionally, the average emergency transfer time during the 19th Asian Games was 12 min; indeed, the effectiveness of transfers received praise from patients. For example, a referee was hit by the hammer throw in an event at the Olympic Stadium. After simple dressing by the FOP medical support staff, the patient was quickly transferred to the designated hospital. The patient arrived at the hospital in 10 min. Surgery was performed within an hour of patient admission. The requirement for designated hospitals to set up independent areas for Asian Games-related treatment facilitated the prompt and timely treatment of severely injured or infected patients. All the hospitalized patients were settled in the Asian Games-designated ward; tests and examinations were also done in the designated areas. These methods helped speed up the treatment process and increase the satisfaction rate of all patients.

The average hospital stay for patients in China is 9.2 days18. During the 19th Asian Games, the median hospital stay for athletes was only three days. The reason for this dramatically lower rate may be the strong medical team chosen for the event and the hospital area segregation. The MCC required designated hospitals to select experienced doctors and nurses to participate in the medical support for the event, which effectively improved diagnosis and treatment efficiency, as well as postoperative recovery. All designated hospitals set up designated wards for all inpatient personnel, expedited all check-ups and examinations, and provided omnidirectional condition for athletes to return to the competition in a timely manner.

Limitations

Our study had several limitations that should be acknowledged. The medical encounters recorded were based on reports by the HAGOC medical support staff. The data did not include information about medical treatment from team physicians. Therefore, the data collected might not be fully representative of the actual medical encounters during the event. Future organizing committees should collect all data on medical encounters from each team’s own physicians, for accuracy.

Conclusion

Despite the challenges brought by the COVID-19 pandemic, the HAGOC provided efficient and reliable medical services during the 19th Asian Games. The MCC provided sufficient care to all the participants while also minimizing the impacts on the local population. The data provided valuable suggestions for future organizing committees of the Asian Games and other large sporting events.