Abstract
Objective
To describe the health conditions treated by a health services center at a Boy Scout summer camp and make recommendations for appropriate resources and supplies.
Methods
We conducted a retrospective review of health center utilization at a Boy Scout camp in central Missouri during the summers of 2012 and 2013. Health logbook data were compiled and analyzed using descriptive and comparative statistics.
Results
During the study period 19,771 camp participants made 1586 visits to the health care center. The overall incidence rate of health center visits was 6.20 visits per 1000 camp days. Two-thirds of visits were for illness and the remainder for injury. Over 90% of patients were returned to camp, 7.3% were transferred to another health facility, and 1.6% were advised to leave camp and return home. The most common treatments were rehydration (17.8 %) and administration of analgesics (13.4%) and topical creams (12.3%).
Conclusions
Summer camps need to be prepared for a wide range of conditions and injuries in youth campers, leaders, and staff members. Over 90% of presenting complaints were managed on site, and the majority of conditions were easily treatable minor injuries and illnesses. We provide recommendations for appropriate medical supplies and suggest opportunities for improvement to aid health centers in planning and treatment.
Keywords
Introduction
More than 11 million individuals attend one of the approximately 12,000 summer camps in the United States annually. 1 Campers are at potential risk for a wide spectrum of injuries and illnesses depending on the camp environment and scope of activities, nevertheless, information on the health care needs of camp participants is limited. The available literature on health issues in summer camps focuses on health risk factors, trends in healthcare center usage, and basic analyses of illness and injuries reported by heterogeneous types of camps and outdoor experiences. 1 –11 These studies, and the guidelines published by the American Academy of Pediatrics,8,12 commonly exclude adults. Several studies have focused on specialized types of camps or populations of campers (such as persons with disabilities), 13 –15 limiting the generalizability of findings. The literature on wilderness travel is limited in applicability to summer camps, and recommendations are not generally evidence-based. 6 ,16–18 This lack of information impedes appropriate planning for efficient treatment and prevention of health issues in participants in summer camps.
This study of youth and adults attending a Boy Scout camp aims to describe the health conditions of patients that presented to the health services center and to make recommendations about appropriate resources to meet those needs. The Boy Scouts of America has 2.3 million members aged 6–17 years, the majority of whom attend a summer camp at least once. 19
Methods
Design and Population Source
This study is a retrospective review of logbook data from the health center of a large Boy Scout camp in the central United States (H. Roe Bartle Scout Reservation, Osceola, MO, 2014). The 4200-acre camp resides in a hilly and densely wooded area in central Missouri. Data from the National Oceanic and Atmospheric Administration database shows a typical summer temperature range of 18.9°C to 43.3°C in the area with average daytime high temperatures of 27.4°C. Six camping sessions of 10 days each are conducted from June to August. Approximately 1600 participants attend each session, for an annual census of over 6600 scouts and 3000 leaders. Each session accommodates about 40 Boy Scout troops. Each Boy Scout troop has an average of 25 Boy Scouts and 5 adult leaders who attend camp. Over 400 camp staff members are present for all 6 sessions. Staff members consist of individuals, aged 16 years or older, who are involved with the Boy Scouts of America and wish to work at the camp and guide campers on merit badge courses, supervised activities, and other camping-related events. Leaders are individuals, over the age of 18 years, who come to camp with their troop and manage the troop campsites and their campers. Leaders are typically parents of campers in the troop or other adult volunteers in the troop. All camp participants, including adults, are required to complete a health history form, obtain a physical examination, and receive approval for participation in activities from his or her personal physician before attending camp. Camp participants are overwhelmingly male and come from a wide range of socioeconomic backgrounds in urban, suburban, and rural communities.
The health center provides health care 24 hours/day when the camp is in session. The center has 4 beds and is equipped with basic equipment including a defibrillator, blood pressure cuffs, glucometer, suture kits, bandages/wraps, and a small supply of prescription and nonprescription medications. No laboratory or radiological capabilities are available. As most medications and supplies are donated, availability is highly variable. Health care is provided by 1 or 2 volunteer physicians from a variety of specialties, including but not limited to orthopedic surgery, pediatrics, cardiology, internal medicine, otorhinolaryngology, emergency medicine, and family medicine. Three to 4 full-time volunteer health professionals assist in patient care administrative duties, including recordkeeping. Patients who require a higher level of evaluation or medical care are transported by private vehicle or ambulance to the nearest hospital, 48 km (30 miles) away.
Data Collection
During the study period all visits to the health center were documented manually in logbooks containing brief descriptions of the injuries or illnesses, examination findings, treatment provided, and disposition. Reasons for individual visits were categorized as illness, injury, prescription medication administration, or patient recheck. Follow-up visits for the same complaint were documented with a new study identification record and were marked as a “patient recheck” instead of an injury or illness. The definition of injury was adopted from that used in military studies as being a traumatic wound or other condition caused by an external force. 20 Prescription medication administration was defined as prescription medication brought by the patient from home, such as growth hormone injections or other medications that the health center administered. Any condition that did not meet criteria for injury, medication administration, or recheck was classified as an illness.
The study covered all logbook entries for camp residents and staff. Entries for visitors and those logbook entries that had missing or illegible data were excluded (n = 27).
Categorical Measurements
Logbook data for 2 consecutive summer camp years (June–August 2012 and 2013) were retrieved by a medical student and entered into a computerized database. The data were categorized by patient age, chief complaint/findings, treatment provided, and disposition. Each patient was assigned a study identification number. No personal identifying information was recorded to ensure patient confidentiality. The University of Kansas Institutional Review Board approved these methods of collection and analysis.
Statistical Analysis
The incidence of reported events is described as rates per 1000 camper days, similar to other camp studies. 1 ,7,18,20 The custom-built database used REDCap database software for secure storage of data. Continuous variables are described using mean and standard deviation, while categorical variables are described using frequency and percentage. The χ2 test was used for comparisons between categorical variables. Logistic regression models were used to calculate odds ratios. Unless specifically stated for a correction, statistically significant differences and associations were identified by P values <.05. All statistical analysis were conducted using SAS v.9.4 (copyright 2002–2012 by SAS Institute Inc, Cary, NC).
Results
During the study period, the 19,771 camp participants made 1586 visits to the health care center. Twenty-seven health center cases were excluded due to missing information. The overall incidence rate of health center visits was 6.20 visits per 1000 camp days (Table 1). The incidence of visits for scouts (7.96) was significantly greater than that for staff (6.33) or leaders (2.83) (P <.05). The most frequent patients seen in the health center were the youngest scouts (median age, 13 years). Over 70% of visits were made by individuals younger than 18 years of age, but 144 (9.1%) visits involved patients over 50 years of age (Table 1).
Demographics of health center patients (2012 and 2013 camp years)
SD, standard deviation.
Illness accounted for 67% of the total health care center visits, followed by injuries (18.2%), follow-up/recheck (13.6%), and prescription medication administration (1.2%) (Table 2). Dermatological conditions, including insect bites/stings were the leading single cause of visits (Table 3). Lacerations, abrasions, and orthopedic–musculoskeletal injuries accounted for the majority of injuries seen at the center (Table 4). No fatalities occurred during the study period.
Distribution of reasons for visit
Distribution of illnesses
SD, standard deviation; HEENT, head, ears, eyes, nose and throat; GI, gastrointestinal.
95% confidence interval.
Distribution of injuries
95% confidence interval
Exploratory logistic regression analysis revealed that laceration was the only injury that had a significant difference in odds ratios between staff and campers and between leaders and campers (Table 5). Dermatologic, gastrointestinal, and respiratory illnesses had a significant difference in odds ratios between staff and campers and between leaders and campers. We found that in our sample, as age increased, the odds of experiencing a laceration; a closed-head injury; a head, ears, eyes, nose, and throat illness; or a gastrointestinal illness decreased (Table 6). The odds of presenting with an abrasion, dermatologic illness, musculoskeletal illness, or cardiovascular illness increased with age (Table 6).
Odds ratios and 95% confidence intervals for injury and illness
CI, confidence intervals; HEENT, head, ears, eyes, nose, and throat; GI, gastrointestinal.
Indicates a Bonferroni correction adjustment requiring P <.0125 for significance.
Indicates a significant value, P <.05 for exploratory analyses.
Odds ratio of injury and illness with age as a continuous variable
OR, odds ratio; CI, confidence intervals; HEENT, head, ears, eyes, nose, and throat; GI, gastrointestinal.
Indicates a Bonferroni correction adjustment requiring P < .0125 for significance.
Indicates a significant value, P < .05 for exploratory analyses.
Over 90% of patients (1444) were treated in the health center and returned to camp activities. Of the remaining 142 patients, 115 (81%) required transfer to another facility and 27 (19%) were sent home by privately owned vehicle. Illnesses were the most common reason for transfer (Table 7) in both campers and leaders and staff.
Distribution of reasons for transfer to another facility
HEENT, head, ears, eyes, nose, and throat; GI, gastrointestinal.
One hundred and fifteen patients were transferred to another facility predominantly because the health center lacked certain imaging or laboratory diagnostic equipment. The odds ratio of requiring a transfer was not statistically different when stratified by age or by camper, staff, and leader. Of the 115 transferred patients, 31 (27%) returned to camp, 21 (18%) did not return to camp because the outside care physician did not provide clearance, and 63 (55%)—or more than half of the total transferred patients—had no outcome recorded because of lack of follow-up communication with the transfer facility.
Oral rehydration was the most common treatment provided, followed by administration of ibuprofen/nonsteroidal anti-inflammatory drugs, topical antibiotic ointment, and oral antibiotics. Cephalosporins, penicillin derivatives, and trimethoprim/sulfamethoxazole were the most common types of oral antibiotics provided. For injuries, the most common treatments utilized sutures, butterfly closures, splints, and crutches. The distribution of recommended supplies is based on the frequency of items used at the health center, grouped by what is required to treat up to 95% of the patient population (Table 8).
Distribution of recommended supplies
NSAID, nonsteroidal anti-inflammatory drugs.
% represents the frequency of items used.
Important items that are rarely needed: automated external defibrillator, oxygen, epinephrine auto-injectors.
Percent needed from this column.
Discussion
The observed overall rate of 6.2 health center visits per 1000 camper days falls within the range of 1.15 to 10 per 1000 camper days reported for camps and wilderness activities. 18 The wide range in the literature may be due to differences in study inclusion or exclusion criteria and type of camp activity. This study shows that Boy Scout camp health providers need to be prepared to treat adults, including staff, as well as adolescents and children. Most conditions seen and treated at the camp health center were minor in nature. Illness accounted for the majority of visits. Close living quarters and contact between individuals during activities could foster the spread of infections. The distribution of illnesses and injuries indicates that most patients require outpatient primary care.
Nearly all of the illnesses and injuries could be treated with a limited supply of medications and equipment. Some transfers may have been prevented if radiograph capabilities were available at the health center; however, this is unlikely to be cost effective. The variability in the skill set of the treating physician could also influence the number of patients transferred. Due to communication limitations, we were unable to determine the outcome for more than half (54.8%) of transferred patients. This failure of information sharing was attributed to misperceptions regarding Health Insurance Portability and Accountability Act regulations or a lack of established protocols for transfers of information to referring providers.
Quality Improvement
The leading illnesses resulting in transfer were for cardiovascular; head, ears, eyes, nose, and throat; and neurological complaints for leaders and staff, compared with head, ears, eyes, nose, and throat; gastrointestinal; and dermatologic conditions in campers (Table 7).
A few simple strategies could improve communication regarding transferred patients. We recommend that all transfer patients carry a records release form, requesting the treating facility to fax patient outcome results back to the camp health center. This protocol would be more effective if established with surrounding hospitals before the camping season. In the health center, complete and legible records are important to monitor services and support quality improvement initiatives. Logbooks should have the same required fields for each patient, recording the chief complaint, findings, treatment, disposition, and follow-up. Electronic logbooks may successfully minimize the legibility errors and facilitate chart reviews and audits while increasing the accuracy, consistency, and ease of data input. 21 Staff training could also improve consistency and completeness of the database.
Supply Utilization
A 1997 study 6 provided evidence-based recommendations for medical supplies for wilderness travel. Although this is useful for first aid kits, residential camps have different medical needs.
Table 8 provides a recommended supply list for camp health centers to provide quick and efficient care for a camp population. The supplies needed to treat up to 75%, 85%, and 95% of the health center population are shown based on our data for treatment supply utilization (Table 8). To treat a larger proportion of patients, a health center should consider having radiograph and basic laboratory facilities on site; unfortunately, such services are unlikely to be cost effective. Camps must also plan for low-frequency, high-consequence emergency events in which timely intervention is critical. Although not needed during our study period, camps should consider having access to automated external defibrillators, epinephrine auto injectors, and other rarely used but potentially life-saving supplies.
Limitations
The study limitations include its restriction to 1 camp during 2 consecutive summer sessions, which limits generalizability of our findings. The study also covers only those treated by the health center. Health conditions in campers may have been undercounted; because Boy Scout training emphasizes first aid and self-sufficiency, a significant amount of minor injuries and illnesses could have been self-treated. In addition, camp-related injury or illness may not be apparent until after the camp session ended. Data collection was limited by the logbook format. Information was recorded at the discretion of the individual responsible for center records each day, and multiple providers resulted in inconsistent recordkeeping that may have contributed to errors regarding disposition or follow-up. Some entries (1.7%) were illegible. Entries on transfer to other facilities did not always specify transport type or differentiate the need for transfer, in particular for those patients requiring further diagnostic imaging or laboratory evaluation versus those requiring a higher level of care.
Conclusions
In our retrospective study of health center utilization at a Boy Scout summer camp, illnesses were far more common than injuries, and the majority of conditions were treatable with a limited list of supplies. We provide evidence-based recommendations for appropriate supplies and suggest opportunities for improvement, including supply preparedness, improved emergency medical services relationships, and communications with hospitals regarding transfers. For camps with limited funds, these data-driven recommendations are essential for appropriate planning and efficient treatment.
Author Contributions: Study concept and design (RM, BB); acquisition of the data (RM); analysis of the data (RM, BB); drafting of the manuscript (RM); critical revision of the manuscript (RM, BB); and approval of final manuscript (RM, BB).
Financial/Material Support: None.
Disclosures None.
Footnotes
Acknowledgments:
We thank the Heart of America Boy Scout Council, especially Alan Sanders and Mark Brayer, for their cooperation and support in providing access to their health record database. We also thank Seamus Murphy and the Department of Emergency Medicine at the University of Kansas Hospital for support on this project. We acknowledge our utilization of the REDCap software in conjunction with the University of Kansas Hospital. REDCap at the University of Kansas Hospital is supported by CTSA Award UL1TR000001, a CTSA Grant from NCRR and NCATS awarded to the University of Kansas Medical Center for Frontiers: The Heartland Institute for Clinical and Translational Research. Thanks also to Anne Walling, MBBS, Amanda Bruce, PhD, David Naylor, MD, and Gary Gaddis, MD for their editorial assistance; and to Alexandra Brown, MS for her statistical analyses assistance.
☆
Presented in poster format at Great Plains Regional SAEM meeting, September 6, 2014, Kansas City, Missouri, and as an oral presentation at the 23rd Annual Winter Meeting of the Wilderness Medical Society, February 15, 2015, Park City, Utah.
Submitted for publication January 2016.Accepted for publication September 2016.