Nurses at financially troubled Howard University Hospital, where 281 employees lost their jobs Tuesday, voted yesterday to reject an indefinite pay freeze requested by the hospital.

Union officials fear their membership's decision could result in up to 30 more dismissals. A Howard University spokesman said yesterday that no further dismissals were planned.

Elaine Cambosos, a staff lawyer for the D.C. Nurses Association, said that the vote was 286 to 27. She said Howard officials had told the Nurses Association last Friday that without an agreement from nurses to forgo cost-of-living increases and merit raises, more of the hospital's unlicensed nurses, pharmicists, dieticians and social workers would lose their jobs.

"People apparently decided that if they are going to have to do more work, they ought to be paid for it," Cambosos said.

The Howard University Hospital nurses' vote came the day after Howard announced it had released 10 percent of its workers and George Washington University Hospital had cut 150 employees, or 6 percent of its staff. In addition, a Capitol Hill Hospital spokeswoman said the hospital likely would dismiss 45 employees, 6 percent of its staff, in the coming weeks.

The hospitals said the staff cuts were necessary because of the high cost of treating a growing number of patients without health insurance and, especially in the case of Howard University Hospital, of keeping patients who no longer need hospital care but have no place else to go.

But some health care officials warned that the dismissals provide only short-term solutions to budget and cash flow problems.

"They don't address the core of the problem we're facing -- consistent underfunding for years coupled with a consistent increase in the number of uninsured patients," said Tom Chapman, president of Greater Southeast Community Hospital.

Hospitals are trying other ways to offset the revenue lost from caring for uninsured people. Since March, patients who go to the Washington Hospital Center emergency room with non-emergency problems are denied care. Instead, hospital employees call one of two federally-funded clinics in the area, make an immediate appointment, and then call a cab for the patient.

Managers of the two clinics said the system is working well. "We have slots," said Toni Wheeler, manager of Shaw clinic.

About five to 15 patients a day are sent by cab to the clinics, said Clare Fiore, director of public affairs for the hospital. She said the patients had complaints ranging from headaches to rashes. A broken arm, for example, would be considered an emergency condition, she said.

"It's cheaper to give them cab fare than to give them hospital care and not get paid for it," Fiore said. "And these people need to establish a regular relationship with a primary physician."

The plan is one of several ways Washington Hospital Center is dealing with increasing financial pressures. This year, for the first time in its history, the hospital expects to lose money: up to $4 million.

The hospital also has arranged to transfer 57 psychiatric beds, which were not fully used, to Capitol Hill Hospital in exchange for 78 medical-surgical beds. Both hospitals are owned by Medlantic Healthcare Group.

In Prince George's County, Dimensions Health Corp., which runs the Prince George's Hospital Center and Greater Laurel-Beltsville Hospital, has entered into partnerships with the private sector to increase revenue. Dimensions also has started a marketing program aimed at securing more paying patients, including advertising its newly renovated obstetrics ward.

George Washington University Medical Center in Foggy Bottom serves a growing number of homeless people who stay between Washington Circle and the State Department and use George Washington's emergency room as though it were their family doctor.

That is going to change, officials said. "If they {the homeless} come in and are sick enough to require hospitalization, fine. But if {care} can be delivered on an outpatient basis, we will refer them" to the appropriate city service, said L. Thompson Bowles, vice president for medical affairs.

Last year, the medical center provided some $30 million in free medical care, but surpluses in other divisions covered all of the losses except for $5 million to $7 million.

Staff writer Larry Thompson contributed to this report.