When less is more: Emergency department staffing in Greece

Greece is a high-income country with over 10 million residents, approximately three times that many annual tourist visits, and about 150,000 refugees from the Middle East. Despite these demands, it has an underdeveloped Emergency Medicine (EM) system, contributing to challenges in access, care quality, system efficiency, and cost. This study aims to: (1) report current staffing in Greek Emergency Departments (EDs), (2) model ED throughput comparing EM-trained and non-EM-trained providers, and (3) propose a national EM dissemination strategy. Staffing and operational data were collected from four representative public EDs in Greece: Nikaia, Volos, Lárisa, and Santorini. Facilities varied in physician coverage (0–5 attendings). We compared potential EM- versus non-EM-trained physician throughput. The only difference between provider types was compatibility with patient demand—EM-trained physicians could manage all chief complaints, while non-EM physicians handled a subset based on their specialty. Other factors like bandwidth (max concurrent patients) and speed (patients/hour) were held constant based on available and recognized standards. An expert panel was convened to propose a national strategy for EM dissemination. Across sites, physician-to-patient ratios ranged from 1:20 to 1:32, with 1–2% of arrivals classified as critically ill. Admission rates ranged from 16–20% (6% in Santorini); 23–28% of patients required specialty consultation. Average ED length of stay ranged from 4.5 to 6.2 hours. Simulations demonstrated that EM-trained staffing reduced physician needs by 53%, driven by a 10.95% increase in throughput (mean 7.83%; 95% CI: 14.2%). Fewer EM-trained attendings were needed (mean reduction 7.26%; 95% CI: 12.47%). These findings likely underestimate benefit, as downstream improvements in quality, access to specialty care, and reduced staffing burden from residents were not modeled. Notably, the lower the staffing level, the greater the benefit of EM-trained physicians. The expert panel endorsed a hub-and-spoke model centered on a national EM center of excellence, launching the first EM residency. With yearly expansion to university hospitals, this model could produce 1,500 EM-trained physicians in 10–15 years. Our model predicts that EM-trained staffing would improve operational efficiency, reduce staffing needs, and potentially yield system-wide benefits and cost savings for the Greek healthcare system.