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Society is aging, which is particularly evident in the growing proportion of patients in trauma care who, in addition to their acute injuries, also suffer from multiple internal medical conditions and mental health issues. The previously used, traditional, isolated trauma care model no longer provides an adequate response to these complex problems, therefore, the University of Pécs Clinical Centre Department of Traumatology and Hand Surgery has developed a structured, integrated orthogeriatric concept that is unique in its complexity even on a national scale. Their goal is not merely to provide surgical care for patients’ injuries, but—by identifying their other diseases and reviewing and reassessing their medication—to heal the whole person, restore their previous condition and independence as much as possible, and improve and maintain their quality of life. By combining surgical excellence, a geriatric approach, structured patient pathways, and measurable quality assurance, they not only improve clinical outcomes but also enhance the safety, efficiency, and sustainability of patient care.

Written by Rita Schweier

“The core principle of our orthogeriatric approach—‘One patient, one team, one shared care plan’—consists of several elements, and its secret lies simply in the fact that we treat the whole person, not just their injury. In addition to the traumatologist, anaesthesiologist, and trained nurses, other key members of our team include a geriatric internist, a physical therapist, a dietitian, a psychologist, and, if necessary, a social worker. It is now internationally proven that these types of multidisciplinary care models improve survival rates, reduce complications, and shorten hospital stays,” stated Dr. Balázs Patczai, senior lecturer and head of the University of Pécs Clinical Centre Department of Traumatology and Hand Surgery.

As he explained, the geriatric internist helps identify patients’ kidney, blood sugar, or other internal medicine issues and manage them as quickly and effectively as possible, even in collaboration with other medical specialties. Through his work, a much more intensive relationship with partner clinics has been established, which he also sees as an improvement. He described his role as essential in the reassessment of medication, the identification of drug interactions, the optimisation of drug therapies, and the improvement of overall condition following the surgery.

He also highlighted the work of dietitians, who assess the patients’ nutritional status. Based on their observations, some patients are malnourished and abnormally thin, while others are overweight and have a poor-quality diet. A rapid, continuous loss of striated muscle is observed in nearly all older adults, affecting not only mobility and physical activity but also metabolism. He pointed out that, in addition to reduced muscle mass, the development, persistence, and manageability of type 2 diabetes are also quite different.

“We tailor nutritional therapy to everyone. We strive to provide patients with nutritional supplements that are high in protein and serve as easily accessible sources of nutrients, which are essential because fractures lead to blood loss and inflammation, making the initial healing stage extremely energy-consuming. In addition, we must also consider the early postoperative period, when attention must also be paid to energising the body and the restoration of muscle function. To better understand this process and improve the effectiveness of individualised nutrition, we conduct both basic and applied research on the topic. We receive significant support in all of this from the UP Clinical Centre Central Dietetic Service,” he added.

Dr. Balázs Patczai emphasised that accidents cause extreme psychological stress in people of all ages. While a middle-aged person may face the threat of losing their job and livelihood, an elderly person may experience dementia resulting from physical and mental decline, as well as delirium and delirious states that frequently occur in hospital settings. In addition to these, the loss of the capability to act and independence is in itself a source of trauma. In such cases, life prospects and goals also vanish.

“Our psychologists work to help patients regain their faith and see their recovery and the future in a positive light. They visit every patient in our care, assess their condition, and then begin the personalised sessions. We receive very positive feedback from both our psychologists and our patients. Sometimes a simple conversation is enough to resolve the issue; in other cases, we can provide longer-term therapy on a limited basis even after being discharged, through our outpatient clinics. It has been proven that properly managed anxiety has a positive effect on pain perception and wound healing, influences rehabilitation activity, greatly aids somatic therapy, and is also capable of reducing the complication rate,” he emphasised.

Early assessment, structured risk assessment and care

Regarding the patient pathway, he explained that under the single-entry system, elderly patients with injuries arrive at the emergency department, where a trauma specialist is always on duty. After the diagnostic results are assessed and a treatment decision is made, the patient is transferred to the traumatology ward, where pain management begins. The timing of the surgery also depends on whether the patient is taking anticoagulant medication or if further testing is required. Upon admission to the ward, a consultation with the anaesthesiologist is conducted, along with a nutritional assessment that includes a questionnaire and the recording of one or two basic parameters. Dr. Balázs Patczai mentioned that within a few weeks, they will likely be able to begin using a device-based measurement method, which is also suitable for the precise examination of inpatients.

The device allows for monitoring changes in body composition, optimising fluid levels in various body compartments, and determining and tracking body fat, muscle, and lean body mass, as well as adjusting long-term nutritional therapy. Upon admission, psychologists also visit the patient, assess their condition, and monitor it periodically. Physiotherapists also meet with the patient and begin physiotherapy and breathing exercises even before the surgery, focusing on the healthy limbs without causing pain. In consultation with the surgeon, they continue the appropriate exercises after the operation as well, following a specific protocol, even on weekends. The internist assists with the work part-time, either by phone or in person, but for many issues—under supervision and with approval—the clinic’s specialists can already find solutions.

He emphasised that one-third of elderly patients with hip fractures die within six months to a year everywhere in the world. It is unclear whether this is due to the injury itself or merely the final straw for an already weakened body. Another third return to their previous level of physical activity relatively quickly after surgery, without requiring significant assistance. The remaining third, while unable to return to their previous condition, can still be effectively rehabilitated. The goal of the team in Pécs is to bring them to the best possible, most active state, as otherwise they would require home care or be placed in nursing homes.

Preventable infections and complications

“This comprehensive approach helps prevent complications and infections and improves patient survival rates, as confirmed by our own surveys conducted at the clinic. We are also skilled at managing infectious conditions; we regularly present on this topic at conferences, continuously educate ourselves, and apply the latest treatments. For pressure ulcers acquired in the hospital, we have anti-decubitus mattresses at our disposal; we can optimise fluid therapy and supplement it with circulatory support and regular physiotherapy. My colleagues can also be of great help in preventing pressure ulcers through applying various positioning techniques and special bandages. When deciding on surgical procedures, we also strive to ensure that the elderly patient can get back on their feet as soon as possible,” he emphasised.

He noted that their clinic takes a very compassionate approach towards patients and their families’ concerns. Their head nurses work hard to find the right rehabilitation facility for elderly patients with injuries—in consultation with their relatives—or to provide home care assistance. He also emphasized, however, that their discharge pathways are complicated because they deal with a specialised patient population, and as a result, securing rehabilitation placements poses a significant challenge. In addition to standard rehabilitation facilities, they collaborate with chronic internal medicine wards.

Future plans: immunological assessment and supportive therapies, robotics

Dr. Balázs Patczai is proud that this comprehensive therapeutic approach is also adopted by other traumatology clinics across the country. They regularly share their experiences with staff from other hospitals who also visit them for observation, and they are also happy to learn from others’ best practices. He added that they have been working according to this approach at the clinic for two years, but the improvement and expansion of their concept is ongoing.

“In developing our concept and approach, we aimed for the global forefront, where models similar to ours had already proven to work well. We adapted these to the Hungarian healthcare and social welfare systems, as well as to our patient population. Examples included the Canadian, Dutch, and German systems, but the healthcare quality management models of Australia and New Zealand are also worth highlighting in terms of the introduction of methodologies, the assessment of results, and the monitoring of various indicators and reporting systems,” he noted.

Speaking about the future, he said he advocates the use of robotics, including companion robots, as well as solutions that support caregiving in various ways. He has set a goal to introduce immunological status assessments and immunological supportive therapies related to surgeries, which will play a significant role in preventing future complications.

Photos:

Dávid Verébi