Last week on the C1 floor at Kings County Hospital, half a dozen men lay on a hodgepodge of ancient stretchers in an open eight-bed ward. A lattice of metal rods hung from the ceiling, bearing tattered blue and green curtains falling off their hooks, which provide the only semblance of privacy afforded to these patients, all victims of trauma.
There is one huge porcelain sink at the end of the room, but for showers for the 60 patients on such floors.
While most hospitals have moved to electrical beds and call buttons, this is strictly a manual operation, with nurses cranking patients up and down. There are no phones and no televisions, although in theory patients may bring their own sets, once hospital engineers have determined that they will not blow a fuse in the building's fragile wiring.
In this room it could well be the 1930's, when the hospital was built, were it not for the whoosh of a respirator sustaining a comatose patient by the door. Kings County, indeed, has long been known as the stepchild of the Health and Hospitals Corporation, a family of 16 hospitals that has struggled with varying success to serve the poorest and sickest patients in New York.
This month, 10 years and more than $100 million into a building plan that would largely replace the hospital, Mayor Rudolph W. Giuliani halted the project, expressing concern that it had been badly mismanaged. And on Thursday, the hospital agency appointed a task force to work on a new design.
In a city where even many private hospitals are also old and crumbling, Kings County has been a symbol of inefficiency and decay, even to the medical personnel who remain dedicated to the place and to the many poor or uninsured, for whom it is the only sure way to gain access to CAT scans or cancer chemotherapy.
'It Needs So Much'
"I've been here over 25 years, and I often wonder if this was a sentence put on me in a previous incarnation," said one doctor who, like most of the dozen doctors and administrators at the hospital interviewed for this story, spoke on condition of anonymity for fear of retribution.
"I love this institution, and it is so important to the community," he said. "But it needs so much. The inpatients' units are a nightmare. It's just a horror to put human beings in these circumstances." Virtually all routine patient care takes place in rooms of 4, 6, 8 or 16-beds.
Dr. Bruce Siegel, Mr. Giuliani's appointee to head the Health and Hospitals Corporation, said: "If you walk through Kings County, it becomes apparent how woefully inadequate it is. The amenities are horrible, it's overcrowded and there are many code violations that we are trying to fix." Although the occupancy rate of the 1,200-bed hospital is only 75 percent, conditions for patients are often cramped, and long waits for appointments and tests are common.
In January 1993, a State Department of Health survey cited the hospital for dozens of shortcomings, from sloppy record-keeping to filthy rooms to fire hazards on numerous floors. Some of the most serious problems stemmed from Federal fire code violations, like dead-end corridors and a lack of automatic sprinklers in storage areas, that were identified as inadequate by Federal regulators as early as 1990. These were supposed to have been fixed by 1992 but were still not repaired by 1993.
They must now be corrected by December, a deadline that Dr. Siegel says the hospital will be able to meet. If it does not, the Government could cut off all money from Medicare and Medicaid, the two Government insurance plans that cover 75 percent of the hospital's patients.
Only Source of Care For Many Patients
But no one expects such a drastic step because whatever its shortcomings, Kings County remains the only hospital -- indeed, the only doctor -- for many of the 700,000 mostly poor and often uninsured people in vast stretches in central Brooklyn. In part because it treats so many uninsured patients, the hospital lost $21.2 million between last June and November, out of an annual budget of $350 million.
Three of the areas served by the hospital -- Bedford-Stuyvesant, East New York and Crown Heights -- were among the 10 worst neighborhoods with respect to health-related problems in a 1992 study by the Health Systems Agency of New York City. The study found that the neighborhoods had rates of high blood pressure, kidney failure and measles two or three times the city average.
A few areas of Kings County Hospital, like the main lobby and the intensive-care unit, have recently been renovated. The lobby is decorated with potted plants and decorated in taupes and tans; intensive care is outfitted with all the latest technology. In the day surgery recovery room, patients resting on purple recliners hooked up to heart and blood-pressure monitors could be at any hospital in the country.
But much of this hulking brick complex is a throwback to a time when the doctors' main tools were rest and sunlight -- hence the huge windows on the hospital's wards.
It is difficult to generalize about the quality of the medical care at a place as vast as Kings County, but doctors say their efforts to deliver humane, high-quality treatments are often hamstrung not just by an aging building, but also by staffing shortages and the hospital's poor organization. While the hospital provides even the uninsured with CAT scans, the physicians say the simpler things are overlooked: rooms are dirty, bedridden patients often miss tests because no staff members are available to transport them, and X-rays are frequently misfiled or lost.
"A lot of people here work hard and want the best for this place, but it doesn't get done because of bureaucratic bungling," said Dr. Kildare Clarke, associate director of the Kings County Emergency Room, who has been there 20 years. "Patient care should be the No. 1 priority, but it's not. There are plenty of administrators, but that doesn't help you get a patient to X-ray."
A List of Deficiencies Longer Than Most
The 1993 State Health Department survey, which outlined 66 deficiencies relating to the delivery of health care at Kings County, was conducted over a three-week period as part of New York's routine review of hospitals in the state. In these surprise inspections, teams from the Health Department fanned out in a hospital, scanning charts, interviewing personnel, inspecting patients' rooms and monitoring the progress of repairs.
Officials at the Health Department insist that the surveys are intended to help hospitals identify needed improvements and are not intended as a yardstick of care; almost all surveys, they say, result in long lists of deficiencies requiring correction. But the 1993 survey at Kings County showed more deficiencies, and more serious deficiencies, than other public hospitals its size.
In addition to the fire code violations, these problems were cited at Kings County:
*Medical care that did not always meet generally accepted standards.
*Emergency-room doctors without trauma certification.
*Poor maintenance. For example, on one day 15 percent of the light bulbs were burned out.
*Failure to keep the hospital clean and orderly. The survey mentions day-old garbage littering operating rooms, heavily soiled shower rooms and urine-filled toilets.
*Lapses in infection control such that even patients with contagious tuberculosis were not properly isolated.
And it is clear from the survey as well as interviews with patients and doctors that the hospital's problems run deeper than an aged physical plant.
8 Hours and a Walk Just for Cough Pills
On a recent morning, dozens of patients with minor medical problems, sitting and standing in the overflowing drab concrete waiting area of the emergency room, could expect to spend hours completing their care. Because of an extreme shortage of primary-care doctors in central Brooklyn, many depend on Kings County for routine medical care.
One 40-year-old woman, who would not give her full name because she is an illegal alien, said she had just spent nearly eight hours at the hospital being treated for a cough. First she went to the emergency room where, after a two-and-a-half-hour wait, the doctor determined that she should be seen in the hospital's urgent-care section, a clinic under the auspices of the emergency room, reserved for patients who turn up there with basic medical problems.
Papers in hand, she trudged through the snow and freezing temperatures to the urgent-care building two blocks away. There, she waited again to see another doctor, who determined that she would need a chest X-ray, which had to been done in the radiology department, near the emergency room. She walked two blocks in the other direction and waited for her films. After another trip in the snow back to the urgent-care center and another wait for her X-ray results, she was finally discharged, pills in hand.
Although waits in hard plastic chairs and inconvenience have long been part of virtually every hospital outpatient department in New York City, critics say the problems reach a new dimension at Kings County. They say Kings County and its more modern affiliate across Clarkson Avenue, University Hospital of the State University of New York Health Sciences Center, have not served the neighborhood well.
Sidique Wai, the director of the New York City Health Crisis Coalition, said: "Kings County Hospital costs $350 million to run. University Hospital of SUNY Health Sciences Center costs $150 million plus. When you put all that money together, you're talking about two institutions costing close to half a billion a year. No one can tell me that this community has gotten half a billion worth of care."
In fact, Mr. Wai and his colleagues are particularly critical of University Hospital, a public institution that he says has courted paying and well-insured patients but has sidestepped care for the poor.
The More Is Done, The More Is Needed
While plans for a new hospital are rethought, officials say Kings County will correct major deficiencies and Federal violations in the existing building as it always has: with stopgap measures. More power and outlets are being installed on the wards, and lines taking central oxygen to more parts of the hospital are under construction. But on wards like C1, patients still get oxygen from huge green tanks by the bedside that must be changed when empty.
The hospital engineering department is putting in smoke barriers and sprinklers on literally dozens of floors, as required by Federal law. But in a 60-year-old hospital it is slow going.
"When you open up a wall in a building this old, you find that there is more than you anticipated to be done," said one hospital official, who estimated that 85 percent of the fire safety violations would be corrected, though not completed, by the end of December.
While some, like Dr. Clarke, would like to see much of the old hospital preserved and renovated, others say that merely patching up older buildings will never be adequate or provide decent patient services. For example, Dr. Siegel said that part of the hospital's housekeeping problem resulted from a shortage of elevators, which patients and maintenance workers had to share.
"You can hire more staff to clean showers better," he said, "but as long as you have inefficient design, it's going to be hard to fix."
