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With the advent of advanced therapies for acute pulmonary embolism (PE), the necessity for risk stratification has become more pronounced. There is a growing interest in establishing dedicated Pulmonary Embolism Response Teams (PERT), which help in rapid identification of intermediate to high-risk cases, and determine the need for advanced interventions.1–3 Multiple scoring systems have been described in the literature, which help in risk stratification of patients in an evidenced-based fashion.4–7 The simplified pulmonary embolism severity index (SPESI) is a wellvalidated and simple to use scoring system to predict 30-day mortality in acute PE.4,5 Cleveland Clinic was one of the early adopters of a multidisciplinary PERT, which was established in October 2014. Our experience over the past 3 years has led us to recognize the difficulty in risk stratification of patients using evidence-based methods like the SPESI score. Three of 6 points of the SPESI score are attributed to vital signs, including systolic blood pressure, heart rate, and oxygen saturation. Typically, there are multiple vital signs charted during evaluation of a patient with suspected acute PE in the initial 6 hours. Vital signs may fluctuate after initial stabilization with fluids, supplemental oxygen, and anticoagulation. Optimal timing of vital signs to calculate a SPESI score has never been addressed in the literature, and this question has come up at multiple occasions during PERT meetings at our institution. Our objective was to study the variability in SPESI score in patients with acute PE, when multiple vital signs were available from the initial encounter up to the first 6 hours from acute presentation. We sought to identify the optimal timing of vitals used to calculate a SPESI score which best predicts 30-day all-cause mortality. This is a retrospective review of the PERT registry at the Cleveland Clinic, a large tertiary care referral center. The study protocol was approved by the Cleveland Clinic Institutional ReviewBoard (StudyNumber 16–547). All patients presenting to ourhealth systemwith a confirmeddiagnosis of acute PE for which PERT was activated between October 2014 and August 2016 were initially reviewed (n 1⁄4 111). Sixty-six patients were excluded as the initial vital signs were not available in the 0to 6-hour window. Thus, 45 patients were included for further analysis (►Fig. 1). We included PERT activations from emergency department (ED) (n 1⁄4 36) and inpatient settings (n 1⁄4 9). We hypothesized four ways of collecting vital signs in 0 to 6 hours of initial presentation to calculate four possible SPESI scores for every patient:

Predictive Scoring for Severity of Acute Pulmonary Embolism: Does Timing Matter?