Low-Risk Pulmonary Embolism Can Be Admitted to the Regular Floor
Patients with low-risk PE—defined by PESI class I/II, simplified PESI score of 0, or meeting Hestia criteria—can be safely managed on a regular hospital floor or even as outpatients, provided they are hemodynamically stable and lack high-risk features. 1
Risk Stratification Framework
The key to determining appropriate admission level is proper risk stratification:
Low-Risk PE (Regular Floor or Outpatient)
- PESI class I or II with 30-day mortality rates of ≤1.6% and 3.6% respectively 1
- Simplified PESI score of 0 with 30-day mortality of approximately 1.0-1.1% 1
- Hestia criteria met (no exclusion criteria present) 2, 1
These patients have demonstrated safety profiles with recurrent VTE rates of 1.7%, major bleeding of 0.97%, and mortality of 1.9% when managed outside intensive care settings 2
Intermediate-Risk PE (Regular Floor with Close Monitoring)
- PESI class III patients who are hemodynamically stable 2
- Patients with right ventricular dysfunction on imaging but no hemodynamic compromise 3
- These patients represent approximately 30% of PE cases and require monitoring for 48-72 hours to detect potential hemodynamic deterioration 4
Patients initially admitted as intermediate-risk (PESI class III) can be considered for early discharge when reassessed at 48 hours and reclassified as low-risk (PESI-48 class I/II or sPESI-48 score of 0). 2
High-Risk PE (ICU Required)
- Systolic blood pressure <90 mmHg or requiring vasopressor support 1, 3
- Cardiogenic shock or persistent hypotension 2, 3
- These patients have approximately 30% mortality and require immediate reperfusion therapy 3
Mandatory Exclusion Criteria for Regular Floor Admission
Even if risk scores suggest low risk, patients must NOT have any of the following to be safely managed on a regular floor 2, 1:
Physiologic Instability
- Heart rate >110 bpm 1
- Systolic blood pressure <100 mmHg 2, 1
- Oxygen saturation <90% on room air 2, 1
- Requiring >24 hours of supplemental oxygen 2
Medical Contraindications
- Active bleeding or recent major bleeding risk 2, 1
- Already on therapeutic anticoagulation at diagnosis 2
- Severe renal failure (creatinine clearance <30 mL/min) 2, 1
- Severe liver disease 2, 1
- Severe thrombocytopenia (platelet count <75,000/mm³) 2
Clinical Factors
- Severe pain requiring intravenous opiates for >24 hours 2
- Need for thrombolysis or embolectomy 2
- PE diagnosed while already on anticoagulation 2
Common Pitfalls to Avoid
Do not automatically exclude patients from regular floor admission based solely on imaging findings of RV dilation. If RV dysfunction is present on CT or echocardiography but the patient is hemodynamically stable, consider measuring cardiac biomarkers (BNP, NT-proBNP, troponin); normal values identify low-risk patients suitable for regular floor care 2, 1
Do not rely on D-dimer or bleeding risk scores beyond the exclusion criteria once a patient has been deemed low-risk by PESI/sPESI/Hestia 2, 1
Ensure consultant or senior clinician review (ST3 or above in acute/specialist medicine, ST4 or above in emergency medicine, or designated advanced nurse practitioners) before admitting to regular floor 2
Anticoagulation Management on Regular Floor
Direct oral anticoagulants (apixaban or rivaroxaban) are first-line therapy for low-risk PE patients on regular floors, with similar efficacy but improved safety compared to traditional heparin bridging 1
For intermediate-risk patients on regular floors, unfractionated heparin is preferred initially due to its short half-life, allowing rapid reversal if clinical deterioration occurs requiring reperfusion therapy 3
Monitoring Requirements
Regular floor patients require 2: