Emergency Department Point-of-Care Specialists: The Greek Model of Emergency Department Efficiency

This is the authors' abstract. We don't add key points for this paper.

Emergency medicine (EM) serves as the cornerstone of evidence-based emergency care, ensuring timely and effective management of acute illnesses and injuries. It encompasses both prehospital emergency services, which provide life-saving interventions at the site of illness or injury, and hospital-based emergency department (ED) care, which offers specialized evaluation and treatment. Over the past several decades, advancements in both prehospital and hospital emergency care have transformed patient outcomes, reduced mortality, and enhanced the overall quality of acute medical services. This dynamic field continues to evolve with innovations in clinical practice, technology, and research, making it an integral part of modern healthcare systems.[1] In recent years, overcrowding in EDs has emerged as a critical challenge, leading to prolonged patient stays, reduced efficiency, disrupted patient flow, and compromised patient safety.[2] Specialty consultations are an essential component of the emergency care continuum, ensuring comprehensive and timely management of critically ill patients. While most hospitals maintain access to trauma surgeons, intensivists, anesthesiologists, cardiologists, and neurologists through on-call systems, it is relatively uncommon for these specialists to be embedded within EDs as point-of-care providers. Several studies have highlighted that delays in specialist input can prolong diagnostic and treatment timelines, adversely affecting patient outcomes and overall ED efficiency.[3,4] Availability of specialty consultation impacts efficiency and length of stay for patients in the ED. A Dutch tertiary care center found that approximately 24% of patients required consultation from another specialty, and these consultations were associated with an approximately 55% increase in ED length of stay.[5] In Greece, EM has been officially recognized as a supraspecialty, established in 2019, building on training in foundational specialties such as internal medicine, surgery, orthopedics, anesthesiology, and cardiology. Physicians from these specialties can acquire EM certification through a 24-month fellowship plus a national examination or via alternative experience-based pathways.[6] Most EDs are staffed by specialists from non-EM backgrounds, with a smaller but growing number holding the supraspecialty. These specialists work in teams, rotating through EDs, taking consultations, and collaborating in delivering emergency care. While the aspiration is for specialists to provide point-of-care presence and immediate specialty advice, this is not yet universally realized in all EDs, especially outside major urban centers. Nevertheless, these developments have improved decision-making speed, specialist input, and patient flow in many hospitals.[6] This model is distinct from merely having specialists available by phone or on call. Instead, Greece has developed a unique collaborative approach in which specialists are physically present within EDs. This approach has proven functional and effective, particularly as the country continues to define boundaries and establish structured training pathways for EM.[6] Emergency-trained physicians are uniquely skilled in resuscitation and evaluating undifferentiated patients across all age groups. Achieving a critical mass of EM-trained and certified physicians is therefore essential for the initial assessment and management of all incoming ED patients. In Greek EDs, once a working diagnosis is established, specialists from other disciplines are readily available to contribute to optimal outpatient treatment selection, arranging investigations, facilitating outpatient services, and making admission decisions. Although debates may occasionally arise among floor specialists regarding which service should assume care, overall ED flow remains uninterrupted, as EM physicians continue evaluating new arrivals. This collaborative model combines the strengths of both systems: EM specialists ensure patient flow and continuity of care, while floor specialists provide immediate, domain-specific expertise.[7] Despite its promise, the model requires further evaluation, particularly as maintaining the constant presence of hospital specialists within the ED increases operational costs. Evidence from European and international studies indicates that consultation rates for specialists can be relatively low, with some being consulted for fewer than one patient per hour of on-site presence. Low utilization is particularly evident among physicians not additionally trained in EM and who restrict their practice to their primary specialty. These patterns raise concerns about efficient use of specialist time and overall cost-effectiveness.[5] The Greek supraspecialty training in EM addresses this gap by providing a structured pathway for specialists from various disciplines to gain formal EM expertise. Physicians undergo a 2-year program at recognized centers and become eligible for board certification in EM.[6] Staffing EDs with such double-certified physicians ensures departments have specialists who bring domain-specific expertise while understanding the core principles of EM. This model promotes continuous intradepartmental learning, facilitates ready access to expert advice, and enhances communication with floor specialists, as interactions are conducted by colleagues familiar with both perspectives. Physician burnout in EDs is a critical issue, often resulting in shortened career spans and threatening the long-term sustainability of the EM workforce.[8,9] Although ED work is inherently stressful and demanding, double-certified specialists can mitigate this burden by maintaining clinical hours in their primary specialty, reducing daily ED workload intensity. Even if midcareer departure from EM becomes necessary, dual certification provides a safety net, allowing physicians to transition back to their primary specialty. Such flexibility may make EM a more attractive career choice, particularly when the trained EM workforce is limited. As the number of these superspecialized physicians grows, further research will be necessary to evaluate efficiency under different staffing and operational scenarios. The point-of-care specialist model in Greece represents a unique approach that could inform solutions to global challenges in emergency care, including ED operations, workforce retention, and overall efficiency. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.