Discharging Low Risk PE from the ED? What do you think?

Guideline from the ACCP(American College of Chest Physicians):  Kearon C et al. Antithrombotic Therapy for VTE Disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST 2012;141 (suppl 2): e419-e494S

Here is a summary:  http://pulmccm.org/2012/review-articles/antithrombotic-therapy-for-dvt-pe-vte-pulmonary-embolism-anticoagulant-accp-recommendations/

LMWH has become quite accepted.  (From the ACCP guidelines): 

"ACCP suggests low-molecular weight heparin (enoxaparin or Lovenox) or fondaparinux instead of unfractionated heparin (Grade 2B-C suggestions). Caveats to this are patients in whom subcutaneous absorption may not be adequate, or patients who are being considered for thrombolytic therapy: they should receive IV unfractionated heparin."

I'm not sure DC to home is ready for prime time.  Not yet "standard of care" but certainly worth considering in the "right patient."  The issue (as you know), like DVT, they need to be relied upon follow up for INR testing and adjustment of Coumadin.  (From the ACCP Guidelines): 

"Patients with low-risk pulmonary embolism (see below) who have good support at home, are likely to follow up, and can inject parenteral anticoagulants (or their family, or home nursing, can inject them) should be discharged home “early,” which means as early as the day of diagnosis, rather than staying in the hospital for 5 days (Grade 2B, suggestion based on moderate strength evidence). These patients can be safely discharged home from the emergency department without hospital admission, suggests the ACCP."

If you do send someone home, you may want to consider calculating a Pulmonary Embolism Severity Index (PESI), (From the ACCP Guidelines): 

The Pulmonary Embolism Severity Index (PESI) is a validated tool the ACCP mentions as a reasonable method of identifying people with low-risk PE. (Click the link for an online calculator.) Scores on the PESI < 85 without hypoxia, systolic BP < 100, severe chest pain, bleeding, thrombocytopenia < 70,000, severe liver or kidney disease, or PE while on anticoagulation suggest low risk PE. There’s also a simplified PESI calculator; a score of 0 suggests low-risk PE

Remember, these are only recommendations.  I do not know of any studies which have actually compared outcomes between low risk PE patients who were hospitalized vs discharged to home from the ED.

Anyone?