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Introduction: High-risk pulmonary embolism (HR-PE) is a leading cause of in-hospital mortality despite advances in risk stratification tools and multidisciplinary Pulmonary Embolism Response Teams (PERT). Gaps in acute PE care, such as inadequate venous thromboembolism (VTE) prophylaxis, lack of comprehensive acute PE evaluation, delay in care escalation/anticoagulation, and underuse of systemic thrombolysis (ST) contributes to poor outcomes. HR-PE cases at Dayton VA were reviewed for guideline concordant care and to guide specific quality improvement interventions. Methods: Single center retrospective study at the Dayton VAMC using VA Informatics and Computing Infrastructure for acute PE admissions Jan 2013 – Dec 2022. Six HR-PE cases were identified after manual review (6/354; 1.7%). Patient characteristics, comorbidities, evaluation, management, and outcomes were collected and analyzed. Results: All 6 HR-PE cases were admitted to the MICU. Each patient had at least one risk factor for VTE, yet 3 received inadequate VTE prophylaxis. 4 patients were anticoagulated with unfractionated heparin (UFH), and 1 with Enoxaparin. Evidence of RV dysfunction (imaging, elevated troponin/BNP) was seen in 5/6 cases. However, none received ST, and only 1 had preemptive anticoagulation with UFH. 5 patients required endotracheal intubation and 4 suffered PEA arrest. 2/6 patients died in-hospital (33.3% mortality). Particularly, 2/6 cases did not undergo echocardiography (TTE) or compression ultrasonography. Conclusions: This retrospective study highlights gaps in acute PE prevention, recognition, and management. It emphasizes the need for systematic review of VTE prophylaxis adherence in this patient population, especially those with comorbidities. Multiple society guidelines recommend ST in acute PE with hemodynamic instability, yet this recommendation was not applied to HR-PE patients. An acute PE protocol which emphasizes clinical indicators, cardiac biomarkers, and early TTE, should reduce heterogeneity of care and facilitate rapid ICU admission and/or interhospital transfer for advanced therapies to optimize outcomes in HR-PE cases. By incorporating effective communication and decision support in a team-based/PERT approach to these individuals, catastrophic RV failure and PE-related mortality can be reduced.