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Report clears Saint Agnes in infection outbreak

State health investigators said Thursday they found no health violations in an inspection of Saint Agnes Medical Center following an infection outbreak last year in the hospital's cardiac surgery unit.

Inspectors "were unable to substantiate any health violations took place," said Kathleen Billingsley, deputy director for the Center for Health Care Quality at the California Department of Public Health.

The state results follow an earlier report by the U.S. Centers for Disease Control and Prevention that was unable to pinpoint a cause for the infections but noted a surgeon with an abnormally high number of affected patients. State health officials also participated in the CDC investigation.

At least 12 patients contracted life-threatening bacterial infections between January 2007 and September 2007 at the Fresno hospital. Three patients died, two likely as a result of the infections, the CDC said.

Hospital officials said the infection rate returned to normal late last year and current patients are not at risk. Kaiser Permanente's Fresno Medical Center, which had stopped sending heart-surgery patients to Saint Agnes after learning of the infection outbreak, has since resumed referring patients to the hospital.

Billingsley said a soon-to-be-released report shows that state inspectors were unable to say "whether there was a piece of equipment or anything like that that contributed to the increased infection rate."

State investigators checked to see whether the hospital met state standards for an infection control, surveillance and prevention program.

Saint Agnes welcomed the news Thursday, although a spokeswoman for the hospital said officials had not yet been contacted by the state.

"We're definitely glad to know that our continued focus on ensuring patient safety through good infection control practices and staff education is validated," said Jamie Huss, hospital spokeswoman.

State inspectors were at Saint Agnes from Feb. 25 to Feb. 27. The hospital had contacted the state and the Fresno County Health Department in October following the increase in cardiac-surgery infections.

The state inspection came on the heels of a separate visit by the CDC, at the hospital's request, in November. A report by CDC physicians pointed to a number of possible causes for the infections.

The CDC team made some recommendations to the hospital and Saint Agnes officials said they reinforced infection-control policies and procedures. No restrictions were placed on Saint Agnes' cardiac surgery program, the hospital or its surgeons.

However, the report from the CDC did note that one surgeon had an abnormally high number of affected patients. The surgeon, who operates at Saint Agnes as part of Stanford University Medical Center's affiliated cardiac program, continues to operate at Saint Agnes, Huss said.

Billingsley, with the California Department of Public Health, praised the hospital for how it handled the situation.

"They're to be commended for reporting this so we had the opportunity to go in there," she said.

However, the family of one patient is disappointed the state's investigation produced no explanations.

"I was hoping for a reason why. I can't tell you what it feels like when you are waiting for information," said Joan Pitcock, whose 75-year-old father Al Pitcock died two weeks after he developed a serious wound infection following a Sept. 10, 2007, open-heart surgery at Saint Agnes.

She said hospital officials confirmed his was one of the reported deaths.

Pitcock questioned the timing of state inspections -- months after the infection problems had subsided.

She is also upset that Saint Agnes didn't tell patients about the infection problem so they could have chosen to have surgery elsewhere. Most patients learned of the problem when it was first reported in The Bee on Nov. 10.

"My dad was sick, but he had some life yet," Pitcock said. "He didn't need to die."

When Kaiser Permanente's Fresno Medical Center learned of the infections in October -- because it contracts with Saint Agnes for open-heart surgery and two of its patients died -- it began sending its cardiac patients to other hospitals including those outside the central San Joaquin Valley.

Kaiser began referring patients back to Saint Agnes on Dec. 17, said Toni Flores, a Fresno Kaiser administrator.

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