In order to evaluate the extent and causes of pain during cardiac implantable electronic device (CIED) implantation in our hospital, a prospective audit over a 23-month period using a patient selfreporting questionnaire was undertaken. In total, 599 procedures were reported, 52.9% for de novo pacemaker implantation and 23.4% for high-energy devices (cardiac resynchronisation therapy defibrillator [CRT-D], implantable cardiac defibrillator [ICD], subcutaneous ICD). Overall, the median pain score was 2/10 (interquartile range 2-4). In total, 61.6% (367/599) reported no pain or mild pain (pain scores 0-3/10), 27.7% (165/599) reported moderate pain (pain score of 4-6/10) and 10.7% (64/599) reported severe pain (pain score of 7-10/10) during the procedure. Significant preimplant worry (odds ratio [OR] 2.13, 95% confidence interval [CI] 1.22 to 3.73) and higher lidocaine doses (OR 1.06, 95%CI 1.00 to 1.11) were associated with severe patient-reported pain. In conclusion, most patients underwent CIED implantation with minimum stress and maximum comfort. An important minority reported severe pain during the procedure. Optimising surgical technique and interventions targeted at reducing pre- and peri-implant worry, particularly in women, and especially in those receiving ICDs, warrants further investigation to reduce patient-reported pain during CIED implantation.

Introduction Cardiac implantable electronic device (CIED) implantation is an increasingly prevalent part of cardiac rhythm management. Adequate procedural pain management is central to the patient experience. The Association of Anaesthetists of Great Britain guidelines state that operators should develop techniques that permit the patient to undergo the procedure with minimum stress and maximum comfort. We developed an audit tool to assess the quality of pain management, and have evaluated the causative factors that can be targeted to optimise the patient experience. Methods A prospective audit was collected over a 23-month period using a patient self-reporting questionnaire. Patients were asked to score their anxiety level prior to, and their pain during the procedure on a 0–10 visual scale. Finally, patients were asked whether the pain matched their expectations. Results 349 near consecutive patients (67% male, age 75±13 years) were included in this audit. There were 167 pacemaker implantations, 42 implantable cardioverter defibrillators, 98 cardiac resynchronisation devices, 13 lead revisions and 29 generator changes. A majority of patients (219, 63%) reported no/mild pain, with 172 (49%) reporting the pain to be less than expected. However, 71 (21%) patients reported the pain to be more than expected, with 56 (16%) reporting severe pain. We wanted to clarify which factors were important in influencing patients’ experience of pain during their procedure. Using a logistic regression model, we investigated whether gender, weight, pre-implant anxiety, device complexity and operator predicted patients' experience of pain. Complex devices are defined as CRT, ICD, or any procedure involving lead extraction. The logistic regression model was statistically significant (χ2 18.8, P=0.002), explaining 14.8% (Nagelkerke R2) of the variance in severe pain and correctly classified 85.8% of cases. Patients with high pre-procedural worry were 2.7 times more likely to experience severe pain. Additionally, female patients were 3.2 times more likely to experience severe pain. Device complexity, operator and patient weight had no impact on pain (figure 1).Abstract 40 Figure 1 Forest plot demonstrating odds ratio (95% CI) derived from logistic regression for the prediction of severe pain Interestingly, there was a weak positive correlation between the quantity of lidocaine usage and perceived pain (R=0.20, P<0.001). It is possible that operators are using more local anaesthetic if patients are complaining of increased intra-procedural pain. Conclusion The majority of patients underwent CIED implantation with minimum discomfort, though an important minority reported severe pain during the procedure. The most significant predictor of pain was a high level of pre-procedure anxiety and therefore interventions targeted at reducing pre- and peri-implant anxiety, particularly in women, warrant further investigation as a means to reduce pain during CIED implantation. Conflict of Interest Nil

Background Cardiologists at Worcestershire Royal Hospital have provided email advice and guidance for local general practitioners. The performance of this service has not been formally evaluated. Methodology Data were collected prospectively throughout 2018 including patient demographics, GP practice, time/date of email and of response, the person responding, the nature of the clinical question and whether admission or clinic appointment was recommended. Patient records were reviewed two months after the email to evaluate outcome. Results In 2018, 2157 email queries were received about patients with a median age of 68 years (IQR 53–77). 52% were male. In total 2145 queries (99.44%) were sent on weekdays, mean of 8.25 per weekday. The median response time was 4 hours 19 minutes (IQR 1.78–17.45 hours), 14.6% received a response in under an hour, 86.1% of queries were responded to within 24 hours and 93.9% within 48 hours. Weekend emails explained the remainder. Overall 91.4% of emails were received between 0800–1700 and 36.2% of responses were sent outside of this time. We estimate 215 consultant hours were taken replying (assuming 6 minutes/email) equivalent to 54 programmed activity (PA) episodes. The most common queries related to interpretation or management of ECGs (44%), ambulatory ECG monitoring (12.5%) or echocardiography (9.2%). In total 73 GP Practices sent emails (mean of 28.6 queries/practice) of which 63 (86.3 %) were from the Worcestershire CCG area. Worcestershire GPs accounted for 97.5% of all queries. Variation exists between individual practices: three did not send any email queries; seven sent only one query over the year and one practice sent 179 queries (8.6% of total). If all practices participated as frequently, the number of emails received would increase five-fold to over 10,000 a year. Of the 10 Cardiology consultants within the deparment, not all participated equally with three consultants replying to 63% of all emails and one replying to 30%. Admission to hospital was recommended in one case and referral to outpatient clinic was recommended in 501 of 2152 cases (23.2%). Of these, a referral was only received within two months in 60.6% of cases. We estimate that this initiative avoided up to 1493 clinic appointments (124 Consultant PA episodes or 2 per week). Potential cost savings to CCG (1493 × £168 for cost of new outpatient consultation) = £250,824. Potential revenue to cardiology for ECG interpretation (44% of 2153 × £25 = £23,683) and for 24 hour holter interpretation 12.5% of 2153 × £45 =£12,110) (Price estimate from NICE Remote ECG interpretation consultancy services for cardiovascular disease MIB152)) Conclusion A cardiology advice and guidance email service is highly efficient use of specialist consultant time with a large number of outpatient clinic appointments being avoided at a cost saving to the CCG. Conflict of Interest None

A 44-year-old woman presented to the emergency department with central crushing chest pain and dynamic anterior ST elevation on a background of a known left bundle-branch block on her electrocardiogram. Past medical history included insulin-dependent diabetes, asthma, fibromyalgia, and a gradually failing kidney transplant. This case demonstrates the rarely utilized niche role for intracoronary thrombolysis in STEMI treatment in the modern angioplasty era.