Two weeks ago today, the Prince George's County Council declared that "an emergency circumstance" and a "threat to public health" exists in the southern area of the county.
These words in the council resolution were suggested by Dr. Francis P. Chiaramonte, owner and director of Southern Maryland Hospital Center in Clinton. His 300-bed hospital is heavily used: occupancy rates so far this year have averaged 97.9 percent. Ambulances carrying emergency cases are told to go elsewhere 30 percent of the time, he said. Patients have been kept in a holding area off the emergency room, in observation rooms and sometimes in the corridors, he said. Sometimes as many as 20 patients are in one of the overflow areas; sometimes for as long as 10 days.
Last summer, Chiaramonte's application for 155 more beds was rejected by Maryland health planners. He then sought help from the council, which passed its resolution supporting his demands. The following day, the doctor was turned down again by the state health planners. Now, blessed with the council's backing and armed with its declaration of an emergency, Chiaramonte plans to try again. He will appeal the decision to the Maryland Health Planning and Development Agency.
Robert W. Sherwood Jr., director of the Southern Maryland Health Systems Agency, which recommended disapproval of Chiaramonte's request, believes the overcrowding at the hospital is Chiaramonte's fault and could be solved without costly expansion.
The "so-called 'problem' has really been contrived," Sherwood said last week. "Rather than solving their problem, the hospital has sought the attention of the media and tried to fault those involved in reviewing their Certificate of Need."
Southern Maryland Hospital, in its effort to gain more beds, has rallied former patients and other supporters, lobbied Annapolis, met with Gov. Harry R. Hughes, sent letters to scores of elected officials and newspapers, invited television crews to the hospital during particularly heavy periods, purchased two pages in the Washington Star last summer to advertise its cause and made its own video tape of crowded holding rooms and hallways.
But Sherwood argues that the hospital does not reserve enough space for emergency admissions. This, he says, has two financial advantages: reserving beds "will generally produce less revenues for the hospital," and scheduling patients ahead of time for nonemergency surgery means the hospital can screen them to see whether they have insurance.
Chiaramonte crowds his hospital by accepting too many nonemergency and elective surgery patients, Sherwood says, so that on the surface, it seems that he needs more' beds. But if the hospital wants to offer emergency services, Sherwood said, it should save enough space to do so.
"It appears that the practices of the hospital are financially and politically beneficial to the hospital, and that is perhaps the basis for their scheduling decision," Sherwood says.
Chiaramonte concedes that some of the patients placed in the emergency room's holding area for lack of regular beds are not emergency patients. Although he has cited these patients as examples of the overcrowding, they are often awaiting nonemergency or scheduled elective surgery.
Speaking of nonemergency cases, Chiaramonte said, "I am not about to redirect anybody" to other hospitals. The amount of preparation made by patients before entering the hospital makes postponement unfair, he said.
Or, as another hospital doctor who supports expansion observed: "Take a guy who has a hernia: for him, because it's interfering with his work, surgery is an emergency. For the doctor, it's elective. For the hospital, it's just another admission."
Chiaramonte said that no specific number or beds are saved for emergency admissions, which account for about 14 percent of all hospital admissions in the area, although "we tried doing it for a while." In this experiment, he said, the hospital set 15 beds aside for emergency admissions, "but 15 beds were filled up in a second." So the hospital no longer does this.
He said it is not fair to keep beds open for patients who may, or may not, arrive by ambulance, while there is a "four-page waiting list" of nonemergency patients.
Although the hospital does accept emergency cases, when the hospital's holding areas are full, ambulances are sent to more distant hospitals, except in "life-and-death" situations.
Cardiologist Danilo Lee believes there is a genuine overcrowding problem and that more beds should be allowed. He said patients kept in the holding area face greater risks. "It's very unfair to them," he said. Not only are they -- or their insurance companies -- paying for regular hospital beds, but "of course, those people are at a higher risk. They don't have the proper equipment that they have in coronary care. It can be done, but it becomes very cumbersome."
Doctors complained of crowding in the holding area at a staff meeting earlier this year. Chiaramonte maintains that all the necessary equipment is available in this area.
"It's not dangerous to bring a patient here in a life-and-death situation," Chiaramonte said. "We are crowded but... we can handle patients efficiently."
In a Nov. 18 letter to William Landis, director of the Maryland Health Planning and Development Agency, however, Chiaramonte complained that overcrowding has made it "quite impossible to provide the service with which we have been charged."
Although every doctor on the hospital staff contacted agreed more beds are needed at the hospital, one doctor, who asked that his name not be published, blamed the hospital for most of the problems.
"The authorities are very reluctant to transfer patients," he said. "They are very protective of their own interest.... The owner of the hospital is making a big issue out of it -- that's the big problem. Eventually we will need some more beds. Eventually it will be granted, I'm pretty sure. What you see now are little political games. There is no emergency as such."
The doctor, who does only elective surgery, said he has never had problems getting patients admitted to the hospital.
Another doctor, family physician Daniel Howell, blamed the hospital planners for the overcrowding. "The problem with the hospital planners is that they tend to lump the county together," he said. More hospital beds are badly needed in the area, he said, and Southern Maryland Hospital is the best place to put them.
Dr. Jagdish Gill, a surgeon who practices at the hospital, said "the problem is definitely there," and centered on the emergency room area. "Electives, you can tell them to go anywhere or wait," he said. "That's no problem at all. It's the emergency patients that are the problem."
Gill said the hospital is overcrowded because it is located in an area of heavy demand, not because it is better or worse than other hospitals. Greater Southeast Hospital in the District, which is nine miles from Southern Maryland Hospital, has an average occupancy rate of 83 percent. Prince George's General Hospital, which is 15 miles away in Cheverly, has a 75.2 percent occupancy rate.
In the meantime, hospitals in the northern part of the county are underused. The Laurel/Beltsville Hospital, for instance, is licensed for 232 beds but is using only 130. These 130 beds have an occupancy rate of only about 75 percent.
Chiaramonte says one of the main reasons for his hospital's popularity is its quality. "We do it better," he said. "We do it cheaper."
He complains that health planners are too interested in "bureaucratic expediency" and do not take the quality of care into consideration when considering applications for expansion.
In its 61-page report recommending disapproval of Chiaramonte's application, the Maryland Health Planning and Development Agency did not mention quality of care. It did, however, consider financial feasibility, the effects of expansion on nearby hospitals and overall area needs.
"I think Dr. Chiaramonte is right," said David E. Brown, director of the county's Foundation for Medical Care, which inspects hospitals for insurance organizations. But "quality is very difficult to measure," he said, adding that he doubted if it could be done under the present health monitoring system.
One of the problems the HSA system faces is that it can approve beds, but it cannot take underused beds away from existing hospitals. As a result, there are almost 100 certified, but unused, beds at Greater Laurel/Beltsville, and 36 unused beds at P.G. General. Hospitals are reluctant to willingly surrender these beds because of the difficulty in obtaining certification in the first place.