The staff at D.C. General Hospital refers to them euphemistically as the "social dispositions."
They are society's castoffs: young and retarded; middle-aged and crippled; old and alone. And they are taking up about 20 percent of the bed space in the city's only public acute care hospital.
Not only are these patients taking up beds, they also are occupying the space in the hospital's busiest departments -- medicine, neurology and orthopedics -- and at times delaying the admission to the hospital of patients who need hospitalization.
The one thing these patients have in common, says Dr. Stanford Roman, D.C. General's medical director, is the fact that they do not belong in a hospital.
Both the "social dispositions" and D.C. General Hospital are victims of a dire shortage of nursing home and chronic care beds in the city. For city social service agencies, patients' relatives and private city hospitals -- where a bed costs an average of almost $300 a day -- dump these patients into D.C. General as a sort of shelter of last resort.
"About one-fifth of our (645) beds are filled with patients who no longer need an acute care hospital," Roman said. "Some of them were not in need of an acute care hospital when they were originally admitted.
"I get at least two or three calls a month from (city) agencies where there is absolutely no reason for the person to go to D.C. General or any other hospital. But what do you say? You're stuck. Sometimes we get holdovers, supposedly awaiting a court evaluation. The court evaluation ends up taking six months."
One of the "social dispositions" is a 65-year-old woman with hypertension who has been in D.C. General since June 28, 1977.
According to the patient's social service record, she ended up in D.C. General after a staff member of a private hospital in the city "took her to DHR (the D.C. Department of Human Resources) and literally left her with a note, like a baby," Roman said.
The woman, whom the hospital has been unable to place in an extended care facility, has been at D.C. General ever since.
Another patient is a 64-year-old man who had suffered a heart attack, was treated at a private hospital in Maryland and then developed gangrene and lost a leg. Two months after the amputation he was transferred to D.C. General with a diagnosis of 'post-cardiac arrest. "What a (case of) dump!" Roman said. The man was in D.C. General from November 1976 through April 1977, and then was readmitted in October 1977 and has been in the hospital ever since.
Roman recounted one incident in which "I got a call from a woman in tears -- and she had to have been coached -- who wanted to know if she could get her mother admitted to D.C. General Hospital."
Roman said he asked the woman what was wrong with her mother and was told "she's had a stroke."
"How long ago did she have the stroke?" Roman asked the woman.
"About a month and a half ago," he says she replied.
When he asked the woman whether her mother had been hospitalized at that time, the woman hesitated and then replied that her mother had been admitted to George Washington University Medical Center and was still there. "The social worker told me to call," Roman says the woman told him.
"I told her the patient is GW's and realistically they should arrange for the patient's disposition." said Roman.
Dr. Dennis O'Leary, GW's medical director, agreed with Roman that that particular patient did not belong at D.C. General. "The real problem in this community is that there are not enough extended-care facilities and people cope with that in a number of ways. But it is not good for the basic health care of the community," said O'Leary. "All the hospitals end up with patients who don't belong in them, but you can't dump the patients out on the street."
The "social dispositions" cause problems of several sorts for D.C. General, said Roman. To start with, they are occupying beds at a time when the hospital is trying, after years of inertia, to improve both its quality of care and its public image.
Also, the presence of these patients interferes with D.C. General's function as a teaching hospital, Roman said. "It's not desirable for teaching," he said, "because you have 20 percent of the patients being followed by doctors who aren't really doing anything for them."
Long-term hospitalization is dangerous for the elderly "social dispositions" because of the infection rate, Roman said. He said that physicians always try to get elderly patients, who are particularly susceptible to infection, in and out of the hospital as quickly as possible.
Another problem faced by the D.C. General staff is the fact that some of the mental patients inappropriately placed in the acute care hospital cause disturbances and are hard to manage.
"We took a guy in who was 19, memtally retarded, with no active medical problems, as a favor to the mental health people. He was in St. Elizabeths but he was going to be evaluated for court and they had no beds available in Area C (Community Mental Health facility). They wanted us to hold him until the end of the week and he was admitted." Roman said.
"The guy started throwing (feces) all over the hospital," Roman said. A psychiatrist recommended that the patient be given a sedative, and he was, for what became a three-week stay. "He was relatively manageable but the nurses were still afraid of him because he allegedly made advances toward two or three of them."
"So the time came when we wanted to send him back to St. E's and when he got there St. E's said they couldn't evaluate him because he was sedated. We had to stop sedating him for 24 hours and he started throwing (feces) again." He was finally transferred back to St. Elizabeths the next morning, Roman said.
In all these cases of dumping, "D.C. General's going to have to give in," Roman said. "The staff will be (angry), but they're going to give in, because if the choice is putting a patient out in the street, they're going to be taken in. But the other institutions always know there's D.C. General."