# VigilCare Clinical — Physician Overview

**An introductory guide for clinicians evaluating the platform**

This document explains what VigilCare does, why it exists, and how it supports bedside and ward-level decision-making. It is written for physicians, advanced practice providers, and nurses. No software engineering background is required.

---

## Table of Contents

1. [Executive Summary](#1-executive-summary)
2. [Clinical Workflow](#2-clinical-workflow)
3. [System Data Flow](#3-system-data-flow)
4. [Dashboard Walkthrough](#4-dashboard-walkthrough)
5. [Clinical Scenarios](#5-clinical-scenarios)
6. [Architecture Overview (High Level)](#6-architecture-overview-high-level)
7. [Safety and Reliability](#7-safety-and-reliability)
8. [End-to-End Journey](#8-end-to-end-journey)
9. [Quick Reference](#9-quick-reference)
10. [Important Caveats for Evaluators](#10-important-caveats-for-evaluators)

---

## 1. Executive Summary

### The problem

Hospitalized patients can deteriorate between scheduled assessments. Early warning signs are often scattered across monitors, the electronic health record (EHR), lab systems, and paper notes. Clinicians must mentally assemble heart rate, blood pressure, respiratory rate, oxygen saturation, temperature, consciousness, and labs into a coherent risk picture — often under time pressure, across many patients, and with incomplete context about recent medications or prior scores.

Missed or delayed recognition of deterioration and sepsis remains a major patient-safety challenge. At the same time, poorly tuned alarms create alert fatigue: too many low-value warnings train staff to ignore the ones that matter.

### What VigilCare is

**VigilCare Clinical** is a **clinical decision support (CDS)** and **continuous ward monitoring** platform. It watches vital signs and laboratory-style observations for admitted patients, applies established clinical scoring systems in near real time, and surfaces **prioritized, explainable alerts** on a ward dashboard so the right clinician can act sooner.

It is **not** a full EHR. It does not replace charting, computerized order entry, pharmacy, or billing. It sits beside those systems as a focused early-warning and sepsis-pathway layer.

### Who it is for

| Role | How they use VigilCare |
|------|------------------------|
| **Bedside nurse** | See ward acuity at a glance, enter vitals, review why an alert fired, acknowledge, track sepsis bundle timing |
| **Physician / APP** | Triage high-NEWS2 and sepsis cases, review score trends and organ dysfunction, prioritize rounds |
| **Charge nurse / supervisor** | Department overview, open alerts, overdue sepsis bundles, handoff reports |
| **Clinical leadership / quality** | Alert-quality feedback, audit trail, threshold oversight |

Primary care settings in scope: **inpatient wards, ICU-style continuous monitoring, emergency and specialty units** (medicine, surgery, cardiology, pediatrics as configured).

### Primary benefits

**For clinicians**

- **Acuity-sorted ward board** — patients ranked by NEWS2 so the sickest rise to the top
- **Standardized scores** — NEWS2, GCS, qSOFA (screening), and SOFA (organ dysfunction) computed consistently from incoming data
- **Explainable alerts** — plain-language “why this fired,” including contributing vitals and recent relevant medications
- **Sepsis pathway discipline** — qSOFA screens for possible infection-related risk; SOFA delta confirms organ dysfunction and starts hour-1 bundle tracking
- **Trend awareness** — rapid vital-sign change can alert even before a value crosses a classic “critical” line
- **Fewer repeated nuisance warnings** — after a clinician acknowledges a suppressible warning, similar low-severity repeats can be quieted for a configurable window (critical alerts are never quieted this way)

**For patients**

- Earlier visibility of deterioration trajectories
- Structured tracking of time-critical sepsis interventions
- Continuity of critical bedside alerts even if the hospital’s central network link is temporarily unavailable (ward gateway design)

**Bottom line:** VigilCare aims to reduce cognitive load, shorten time-to-recognition, and support — never replace — clinical judgment.

---

## 2. Clinical Workflow

VigilCare fits into the work you already do. It does not invent a new model of care; it accelerates recognition and organizes what you already interpret.

### From admission to action

```mermaid
flowchart LR
  A[Patient admitted<br/>encounter opened] --> B[Vitals & labs<br/>arrive continuously]
  B --> C[Scores update<br/>NEWS2 · GCS · qSOFA · SOFA]
  C --> D[Alerts appear<br/>on ward board]
  D --> E[Clinician reviews<br/>and acts]
  E --> F[Acknowledge / escalate<br/>bundle / reassess]
```

| Step | What happens clinically | What VigilCare does |
|------|-------------------------|---------------------|
| **1. Admission** | Patient registered; inpatient (or ED) encounter opened; room/bed assigned | Creates the encounter context that all observations and alerts attach to |
| **2. Monitoring** | Bedside monitors, nurses, and labs generate measurements | Ingests observations (directly, via FHIR/integration engine, or ward gateway) |
| **3. Scoring** | You would normally recalculate NEWS2 / think through sepsis criteria | Continuously recomputes NEWS2, GCS, qSOFA, SOFA, and rate-of-change trends |
| **4. Alerting** | Someone notices a concerning pattern — or misses it | Raises threshold, composite-score, trend, or sepsis-pathway alerts with severity |
| **5. Triage** | Charge nurse or physician prioritizes who to see next | Virtual Ward sorts by NEWS2; Critical / Alerts / Active Sepsis filters |
| **6. Assessment** | Bedside review of vitals, meds, trajectory | Patient Detail: trends, score history, alert reasoning, orders, bundle status |
| **7. Response** | Orders, fluids, antibiotics, escalation of care | Acknowledge/resolve workflow; hour-1 sepsis bundle checklist; optional handoff report |
| **8. Continuity** | Night shift inherits the picture | Audit trail of acknowledgments; SBAR-style handoff; escalation if no ack in time |

### How sepsis is handled (Sepsis-3 aligned)

VigilCare follows a two-step clinical logic that matches modern sepsis practice:

1. **qSOFA ≥ 2** → **screening alert** (“consider sepsis workup / order SOFA labs”). This is **not** a sepsis diagnosis and does **not** start the treatment bundle.
2. **SOFA rise of ≥ 2 from the patient’s baseline** → **`SOFA_SEPSIS` critical alert** and automatic **hour-1 bundle tracking** (blood cultures, lactate, broad-spectrum antibiotics, IV crystalloid 30 mL/kg).

This separation reduces over-calling sepsis from bedside screens alone while still accelerating recognition when organ dysfunction is confirmed.

### What you do vs. what the system does

| Clinician owns | System supports |
|----------------|-----------------|
| Diagnosis and differential | Pattern detection and score calculation |
| Ordering and treatment decisions | Suggested bundle elements and countdown visibility |
| Whether an alert is clinically meaningful | Explainable reasoning + feedback ratings |
| Escalation of care (RRT, ICU) | Escalation status if an alert sits unacknowledged |
| Final accountability for the patient | Audit trail of who saw what and when |

---

## 3. System Data Flow

Think of VigilCare as a clinical assembly line: raw measurements enter, are checked for quality, scored with standard tools, then presented as prioritized work for the care team.

### Overview

```mermaid
flowchart TB
  subgraph sources [Data sources]
    EHR[EHR / integration engine<br/>HL7 → FHIR]
    MON[Bedside monitors<br/>& devices]
    LAB[Lab systems]
    NURSE[Manual vitals entry<br/>on dashboard]
    GW[Ward gateway<br/>local buffer]
  end

  subgraph ingest [Ingestion & quality]
    API[Clinical ingest<br/>REST or FHIR]
    VAL[Validation<br/>plausible ranges, duplicates]
    NORM[Normalization<br/>units & codes mapped]
  end

  subgraph score [Clinical intelligence]
    TH[Instant thresholds<br/>critical / warning]
    SC[Scoring engines<br/>NEWS2 · GCS · qSOFA · SOFA]
    TR[Trend / rate-of-change]
  end

  subgraph alert [Alert management]
    GEN[Alert generation<br/>+ plain-language explanation]
    PRI[Prioritization<br/>Critical vs Warning]
    SUP[Suppression<br/>after ack of warnings]
    ESC[Escalation<br/>if unacknowledged]
  end

  subgraph ui [Clinician surface]
    DASH[Dashboard<br/>ward · patient · alerts · sepsis]
    ACK[Acknowledge / resolve<br/>feedback]
  end

  EHR --> API
  MON --> API
  LAB --> API
  NURSE --> API
  GW --> API
  API --> VAL --> NORM
  NORM --> TH
  NORM --> SC
  NORM --> TR
  TH --> GEN
  SC --> GEN
  TR --> GEN
  GEN --> PRI --> SUP
  PRI --> ESC
  PRI --> DASH
  ESC --> DASH
  DASH --> ACK
  ACK --> SUP
```

### 3.1 Data ingestion

| Source | Plain-language role |
|--------|---------------------|
| **EHR / integration engine** | Hospital systems can send patients, encounters, observations, and medication administrations using a standard health-data format (FHIR R4), often via an interface engine such as Mirth Connect |
| **Bedside monitors & devices** | Continuous or intermittent vitals stream into the same clinical ingest path |
| **Laboratory systems** | Results (lactate, creatinine, platelets, bilirubin, blood gas, etc.) feed organ-dysfunction scoring |
| **Dashboard vitals entry** | Nurses can record a vitals set at the bedside when devices are not auto-feeding |
| **Ward gateway** | A local ward server can keep accepting data and raising critical alerts if the link to the central hospital systems is down, then sync when connectivity returns |

Each measurement is stored against an **encounter** (one hospital stay/episode), not floating free — the same way you think about “this admission’s vitals.”

### 3.2 Validation and normalization

Before scoring:

- Values are checked for **clinical plausibility** (e.g., absurd heart rates rejected)
- **Duplicate retries** from devices are ignored safely (idempotent ingest)
- Codes and units are **mapped to a common clinical vocabulary** (e.g., LOINC → internal observation codes; °F → °C when needed)

This step exists so scoring engines see comparable, trustworthy inputs.

### 3.3 Clinical rules and scoring

| Tool | Clinical question it answers | What triggers attention |
|------|------------------------------|-------------------------|
| **Instant thresholds** | Is this single value dangerous right now? | Critical or warning bands for HR, SpO₂, BP, temperature, K⁺, lactate, glucose, etc. |
| **NEWS2** | How high is general deterioration risk? | 5–6 (or any single parameter = 3) → warning; ≥ 7 → emergency |
| **GCS** | What is consciousness level? | 9–12 warning; ≤ 8 critical; also feeds NEWS2 and qSOFA/SOFA |
| **qSOFA** | Should I screen for possible sepsis-related risk at the bedside? | ≥ 2 of: RR ≥ 22, SBP ≤ 100, altered mentation |
| **SOFA** | Is there new organ dysfunction vs this patient’s baseline? | Delta +1 warning; delta ≥ 2 → sepsis pathway + hour-1 bundle |
| **Trend detection** | Is something getting worse *fast*, even if still “in range”? | Rate-of-change thresholds over ~30 minutes (e.g., rising HR/RR, falling SpO₂/SBP) |

**NEWS2 parameters (7):** respiratory rate, SpO₂, systolic BP, heart rate, consciousness (GCS preferred, else AVPU), temperature, supplemental oxygen.

**SOFA organs (6):** respiratory, coagulation, liver, cardiovascular, CNS, renal. Labs older than 24 hours are treated cautiously (stale contribution dropped); 12–24 hour labs are flagged as aging.

### 3.4 Trend analysis and alert generation

Alerts are created in layers:

1. **Immediate critical values** — evaluated as soon as the observation arrives (patient-safety priority)
2. **Composite scores** — NEWS2, GCS, qSOFA, SOFA recalculated as new pieces of the puzzle arrive
3. **Trends** — rapid deterioration even without crossing a classic critical number

Composite alerts carry an **immutable explanation**: which parameters contributed, trend context when relevant, recent medication context when relevant, and a short bedside narrative.

### 3.5 Prioritization, suppression, and escalation

```mermaid
flowchart TD
  A[New alert] --> B{Severity?}
  B -->|Critical| C[Always visible<br/>never suppressible]
  B -->|Warning| D[Visible; may be<br/>suppressible after ack]
  C --> E[Clinician inbox / ward]
  D --> E
  E --> F{Acknowledged<br/>within ~5 min?}
  F -->|Yes| G[Status: Acknowledged<br/>optional note]
  F -->|No| H[Status: Escalated<br/>backup notified]
  G --> I{Suppressible<br/>warning type?}
  I -->|Yes| J[Quiet similar repeats<br/>for configured window]
  I -->|No| K[Continue monitoring]
  G --> L[Later: Resolve<br/>when clinically closed]
```

| Mechanism | Clinical intent |
|-----------|-----------------|
| **Critical vs Warning** | Separate “interrupt now” from “review soon” |
| **Deduplication** | Avoid stacking identical open screens (e.g., one open qSOFA screen) |
| **Suppression window** | After acknowledging a *warning*, reduce repeat noise of the same type for a period (default on the order of tens of minutes; configurable) |
| **Never suppress** | Critical vitals/labs, NEWS2 emergency, GCS ≤ 8, SOFA sepsis, rapid deterioration |
| **Escalation** | If still open after the acknowledgment timeout (~5 minutes), mark escalated for backup response |
| **Medication annotation** | If a recent drug (e.g., beta-blocker) may explain bradycardia or hypotension, the alert **still fires** but shows that context so you can interpret it |

### 3.6 Dashboard presentation

The dashboard is the clinician’s workplace surface: ward list, patient deep-dive, hospital-wide alert inbox, sepsis bundle board, and department overview. Details are in [§4](#4-dashboard-walkthrough).

### 3.7 Clinician acknowledgement and feedback loop

```mermaid
flowchart LR
  A[Alert presented] --> B[Review reasoning]
  B --> C[Clinical action<br/>outside or alongside system]
  C --> D[Acknowledge]
  D --> E[Optional: rate alert quality]
  E --> F[Quality analytics]
  F --> G[Threshold / rule tuning<br/>over time]
  D --> H[Resolve when done]
```

After reviewing an alert, clinicians can rate it (useful, would act, too early, too late, false positive, missing context). Aggregated ratings feed an **alert quality** view so the platform can be tuned with clinician input rather than only engineering assumptions.

---

## 4. Dashboard Walkthrough

### 4.1 Virtual Ward

**Purpose:** Answer “Who on this floor needs me first?”

| You see | How to interpret | Actions |
|---------|------------------|---------|
| Patient list sorted by **NEWS2** (highest first) | Acuity order for rounds / safety huddles | Open a patient row for detail |
| NEWS2, qSOFA, sepsis, open-alert columns | Multi-signal glance without opening the chart | Sort by any column; search name/MRN |
| Filters: Critical (NEWS2 ≥ 7), Has Alerts, Active Sepsis, department | Narrow to the unstable subset | Toggle filters for charge-nurse triage |
| **Handoff report** | Structured SBAR-style summary of visible patients | Generate for shift change; print/export as allowed |

### 4.2 Department Overview

**Purpose:** Unit- and hospital-level situational awareness.

| You see | How to interpret | Actions |
|---------|------------------|---------|
| Counts of active patients, NEWS2 ≥ 7, open alerts, active sepsis bundles | Load and acuity of the service | Drill toward ward or sepsis board |
| Per-department acuity bars | Which units are under pressure | Prioritize staffing / senior review |

### 4.3 Patient Detail

**Purpose:** Full clinical review for one encounter.

| Section | Information | Clinical use |
|---------|-------------|--------------|
| **Patient banner** | Demographics, allergies, emergency contact, blood type | Safety context before acting |
| **Scores** | Current NEWS2 risk, SOFA with organ breakdown, GCS components | Snapshot of acuity and organ failure |
| **Latest vitals** | Most recent measurements | Confirm what the scores are based on |
| **Vitals entry** | Manual recording of a vitals set | Bedside documentation into the monitoring stream |
| **Active alerts** | Open warnings/criticals for this patient | Click a row for explanation |
| **Alert reasoning** | Plain-language narrative, score contributors, med context | Decide if this is pathology, pharmacology, or artifact |
| **Orders** | Labs, antibiotics, fluids, etc. tracked in-system | See what has been ordered/resulted in this pathway |
| **Sepsis bundle** | Four hour-1 elements + compliance clock | Drive timely sepsis interventions |
| **Vital charts** | HR, RR, SBP, SpO₂, temperature with **medication markers** | Correlate spikes/dips with drug administration |
| **Score histories** | NEWS2, SOFA, GCS, qSOFA over time | Trajectory — improving vs worsening |
| **Encounter timeline** | Chronology of status changes, observations, alerts | Reconstruct the story of the stay |
| **Discharge summary panel** | Available when discharging | Close the episode with structured summary support |

### 4.4 Alert Center

**Purpose:** Hospital-wide inbox independent of any one patient.

| Tab | Meaning |
|-----|---------|
| **Open** | Needs attention |
| **Acknowledged** | Seen; clinical response may still be in progress |
| **Resolved** | Closed |
| **Escalated** | Missed acknowledgment window — backup path |

**Actions:** Acknowledge (with role-aware note), then Resolve. Critical alerts may also trigger an audible tone / browser notification on the dashboard.

### 4.5 Sepsis Bundle Board

**Purpose:** “Which sepsis clocks are ticking?”

Bundles are sorted by urgency: **overdue → at risk (&lt; 15 minutes remaining) → on track**. Each shows the four hour-1 elements and countdown from recognition.

**Clinical note:** Bundle elements in VigilCare are **decision-support tracking** linked to in-system orders. In a live hospital deployment they would need to be connected to real CPOE/pharmacy workflows; they do not by themselves dispense medication.

### 4.6 Alert Quality / Feedback

**Purpose:** Continuous improvement of alerting.

Clinicians rate alerts; leadership reviews false-positive rates, acknowledgment patterns, and usefulness by alert type.

### 4.7 Administrative / operations views (awareness)

| View | Why clinicians should care |
|------|----------------------------|
| **Threshold management** | Local policy for warning/critical bands (admin-governed) |
| **Audit log** | Who acknowledged what, when — governance and M&M support |
| **Reconciliation / data quality** | Flags gaps such as disconnected-monitor style issues |
| **Gateway operations** | Whether a ward is online, degraded, or buffering during outages |

---

## 5. Clinical Scenarios

These scenarios mirror the kinds of trajectories the platform is designed to detect (including built-in simulator cases used for clinician evaluation).

### Scenario A — Elderly UTI progressing to sepsis

**Story:** An 82-year-old woman is admitted with urinary tract infection. Over hours, respiratory rate rises, systolic BP drifts down, and mentation becomes cloudy.

| Phase | Data / scores | VigilCare assistance |
|-------|---------------|----------------------|
| Early | Mild vital changes | Ward list may still look relatively calm |
| Screen | RR ≥ 22, SBP ≤ 100, GCS &lt; 15 → **qSOFA ≥ 2** | `QSOFA_SCREEN` warning: consider SOFA labs / sepsis workup |
| Confirmation | Rising creatinine, falling platelets, worsening GCS → **SOFA delta ≥ 2** | `SOFA_SEPSIS` critical alert + hour-1 bundle with countdown |
| Response | Cultures, lactate, antibiotics, fluids ordered/resulted | Bundle board shows compliance vs deadline |
| Continuity | Night team takes over | Handoff report + open alerts + audit of who acknowledged |

**Decision support value:** Separates “screen positive” from “organ dysfunction confirmed,” and makes the hour-1 clock visible.

### Scenario B — Post-operative occult hemorrhage

**Story:** After surgery, heart rate climbs and blood pressure/SpO₂ trend downward while the patient still “looks okay” between checks.

| Signal | VigilCare role |
|--------|----------------|
| Individual vitals entering warning/critical bands | Immediate threshold alerts |
| Steep slope of HR up / SBP down | `RAPID_DETERIORATION` even before classic critical cutoffs |
| Rising NEWS2 | Patient climbs the ward sort order |
| Charts + med markers | Distinguish bleeding physiology from recent analgesic/sedative effects |

**Decision support value:** Trajectory and composite risk, not only single snapshot values.

### Scenario C — Neurological decline

**Story:** Traumatic brain injury or post-neurosurgical patient with serial neuro checks.

| Signal | VigilCare role |
|--------|----------------|
| Falling eye/verbal/motor scores | GCS warning → critical as total drops |
| GCS history chart | Makes the drop from 14 → 10 over hours unmistakable |
| Downstream effects | NEWS2 consciousness, qSOFA mentation, SOFA CNS update |

**Decision support value:** Turns intermittent GCS documentation into a visible neurological trajectory.

### Scenario D — Medication-related “false alarm” context

**Story:** A patient receives metoprolol; heart rate and blood pressure fall into warning ranges.

| What happens | Clinical nuance |
|--------------|-----------------|
| Warning / NEWS2 alerts still fire | Safety: do not hide potentially real deterioration |
| Alert reasoning shows recent beta-blocker | Supports interpretation: drug effect vs shock |
| Clinician may ack + rate as “false positive” or “missing context” if appropriate | Feeds alert-quality improvement |
| Suppressible warnings can quiet repeats after ack | Reduces fatigue while criticals remain live |

**Decision support value:** Context without silencing the alarm prematurely.

### Scenario E — Ward isolation during network failure

**Story:** Central hospital uplink fails (e.g., severe weather). Bedside monitoring must continue.

| What continues locally | What syncs later |
|------------------------|------------------|
| Observation buffering on the ward gateway | Backlog of vitals/labs to central |
| Critical/warning alerting at the ward | Acknowledgments without duplicate pages |
| Ops visibility of degraded/offline gateways | Full audit trail after reconnection |

**Decision support value:** Monitoring continuity is treated as a clinical safety requirement, not only an IT concern.

---

## 6. Architecture Overview (High Level)

You do not need to know how the software is built to use it. This section only explains the major “rooms” of the hospital metaphor — enough to trust reliability and boundaries.

```mermaid
flowchart TB
  subgraph clinicians [Clinicians]
    UI[Ward dashboard<br/>browser application]
  end

  subgraph brain [Clinical brain]
    API[Central clinical service<br/>stores data · runs rules · serves the dashboard]
  end

  subgraph edge [Ward edge]
    WG[Ward gateway<br/>keeps working if the network drops]
  end

  subgraph memory [Clinical memory & messaging]
    DB[(Durable patient record)]
    CACHE[(Fast short-term state<br/>for scoring windows)]
    BUS[[Event stream<br/>many listeners in parallel]]
    PAGE[[Notification / escalation path]]
  end

  UI <--> API
  WG <--> API
  EHR[Hospital EHR / labs / devices] --> API
  EHR --> WG
  API --> DB
  API --> CACHE
  API --> BUS
  BUS --> API
  API --> PAGE
```

| Component | Everyday analogy | Clinical contribution |
|-----------|------------------|------------------------|
| **Dashboard** | The ward whiteboard + patient chart view | Where you see acuity, alerts, trends, and act |
| **Central clinical service** | The always-on clinical calculator and filing clerk | Validates data, stores the record of truth, computes scores, creates alerts |
| **Ward gateway** | A backup charge desk that keeps working in a blackout | Local continuity during network partition |
| **Durable database** | The permanent paper chart (electronic) | Source of truth for encounters, observations, alerts, audit |
| **Short-term state store** | Scratch pad for “vitals in the last few hours” | Assembles NEWS2/qSOFA/SOFA windows quickly |
| **Event stream** | Overhead announcement that many teams hear at once | Lets scoring, search, and archiving proceed independently without blocking ingest |
| **Notification path** | Paging hierarchy | Escalates if nobody acknowledges in time |
| **FHIR / integration facade** | Hospital interpreter between vendor systems | Lets EHR ecosystems send/receive standard clinical resources |

**Design principle that matters clinically:** critical single-value breaches are handled with highest urgency on ingest; richer composite scoring runs immediately afterward in parallel so one heart-rate reading can update NEWS2, trends, and sepsis screens together.

---

## 7. Safety and Reliability

### Minimizing false positives (without hiding true danger)

| Safeguard | Effect |
|-----------|--------|
| Separate **warning** vs **critical** severity | Reduces “everything is red” |
| **qSOFA ≠ sepsis diagnosis** | Screening does not auto-start bundles |
| **SOFA baseline + delta** | Alerts on *new* organ dysfunction, not chronic abnormality alone |
| **Medication context** | Helps interpret pharmacology-related vital changes |
| **Suppression after clinician ack** | Quiets repeat *warnings* only; criticals always break through |
| **Deduplication** | One open screen/alert of a type instead of a stack of clones |
| **Clinician feedback ratings** | Measures real false-positive burden for tuning |

### Preventing missed deterioration

| Safeguard | Effect |
|-----------|--------|
| Continuous multi-score surveillance | NEWS2 + thresholds + trends + sepsis pathway |
| **Rapid deterioration** alerts | Catches velocity before absolute critical values |
| Ward list sorted by NEWS2 | Systematic prioritization |
| **Escalation** on unacknowledged alerts | Backup if the first clinician is occupied |
| **Lab staleness handling** in SOFA | Avoids false reassurance from ancient labs |
| **Ward gateway continuity** | Critical monitoring during uplink loss |
| Data-quality / reconciliation views | Surface gaps in monitoring feed |

### Auditability

Clinical write actions — including alert acknowledgment/resolution, threshold changes, and encounter transitions — are recorded in an **append-only audit log** with who, what, when, and relevant before/after context. This supports governance, quality review, and understanding of the care timeline.

### Clinician oversight — not replacement of judgment

VigilCare is explicitly positioned as **decision support**:

- Alerts explain themselves; they do not issue diagnoses
- Bundle tracking does not replace the clinician’s order decisions or live pharmacy systems
- Acknowledge / resolve / feedback keep a human in the loop
- Role-based access limits who can change thresholds or view administrative audit tools

**The clinician remains accountable for assessment and treatment.** The system’s job is to make deterioration harder to miss and easier to explain.

---

## 8. End-to-End Journey

A single concrete walkthrough — **Mrs. Chen, 78, admitted with suspected pneumonia** — from first data point to clinician action.

### Step 1 — Encounter opens

Mrs. Chen is registered with an MRN. An **active inpatient encounter** is opened on the medical ward (room, attending, admission reason recorded). VigilCare now has a container for all observations and alerts for this stay.

### Step 2 — Data begins to flow

Over the next hours, measurements arrive from mixed sources:

- Bedside monitor / nurse vitals: HR, RR, BP, SpO₂, temperature, oxygen use  
- Consciousness: GCS components (or AVPU)  
- Labs: CBC, chemistries, lactate as ordered  
- Medications: e.g., antibiotics, antipyretics as administered  

Each value is validated, stored against her encounter, and passed to scoring.

### Step 3 — Early composite picture

When enough NEWS2 parameters are present, a **NEWS2 score** appears on the Virtual Ward. Mrs. Chen may sit mid-list initially (e.g., NEWS2 3–4).

GCS is tracked; it also informs consciousness for NEWS2 and mentation for qSOFA/SOFA.

### Step 4 — Bedside sepsis screen turns positive

RR rises to 24, SBP falls to 98, GCS drops to 14.

**qSOFA criteria = 3.** VigilCare raises a **`QSOFA_SCREEN` (warning)** with an explanation: which criteria are active and that SOFA labs / sepsis evaluation should be considered. The ward list and Alert Center show the new open alert. **No sepsis bundle starts yet.**

### Step 5 — Organ dysfunction confirmed

Labs return: creatinine up, platelets down; cardiovascular and respiratory SOFA components worsen. Compared with Mrs. Chen’s **SOFA baseline** (established once enough organ data existed), the **delta is ≥ 2**.

VigilCare raises **`SOFA_SEPSIS` (critical)** and creates an **hour-1 bundle** with four tracked elements and a one-hour deadline. The Sepsis Bundle Board now shows her countdown. A critical banner/notification can draw immediate attention.

### Step 6 — Concurrent safety nets

Meanwhile:

- If SpO₂ briefly hits a critical band, a **critical threshold alert** fires immediately  
- If HR climbs steeply over 30 minutes, **rapid deterioration** may fire even before a classic critical HR  
- NEWS2 may cross ≥ 7 → **`NEWS2_EMERGENCY`**, moving her to the top of the ward sort  

### Step 7 — Clinician review

The charge nurse opens **Patient Detail**:

- Banner confirms allergies  
- Scores show NEWS2 high, SOFA elevated with organ breakdown, GCS trend down  
- Charts show the vital trajectory; medication markers show recent administrations  
- Alert reasoning narrates why `SOFA_SEPSIS` fired  
- Bundle panel lists cultures, lactate, antibiotics, fluids  

### Step 8 — Action and acknowledgment

The physician reviews, initiates clinical orders in the hospital workflow, and in VigilCare **acknowledges** the critical alert with a note. Acknowledgment is audit-logged. Escalation timer stops for that alert.

As bundle-linked elements are completed/resulted in-system, the bundle moves toward **COMPLIANT** (within the hour) or **NON_COMPLIANT** (past deadline) — making timeliness visible for the team and for quality review.

### Step 9 — Feedback and handoff

The clinician optionally rates the alert (“useful / would act”). At shift change, a **handoff report** summarizes Mrs. Chen among other high-acuity patients. The night team inherits open items, score trends, and the audit trail of daytime acknowledgments.

### Journey map

```mermaid
sequenceDiagram
  participant Src as Monitors / EHR / Labs
  participant VC as VigilCare
  participant RN as Nurse
  participant MD as Physician

  Src->>VC: Vitals & labs for Mrs. Chen
  VC->>VC: Validate · store · score
  VC->>RN: Ward list updates NEWS2
  Note over VC: qSOFA ≥ 2
  VC->>RN: QSOFA_SCREEN warning
  RN->>MD: Sepsis workup / SOFA labs
  Src->>VC: Organ dysfunction labs
  Note over VC: SOFA delta ≥ 2
  VC->>MD: SOFA_SEPSIS + hour-1 bundle
  MD->>VC: Acknowledge alert
  MD->>VC: Bundle elements completed
  VC->>RN: Compliance status visible
  RN->>MD: Handoff report at shift change
```

---

## 9. Quick Reference

### Alert types you will commonly see

| Alert family | Typical meaning | Usual severity |
|--------------|-----------------|----------------|
| `CRITICAL_*` / `WARNING_*` | Single vital or lab outside configured bands | Critical / Warning |
| `NEWS2_WARNING` / `NEWS2_EMERGENCY` | Early warning score medium / high | Warning / Critical |
| `GCS_WARNING` / `GCS_CRITICAL` | Moderate / severe consciousness impairment | Warning / Critical |
| `QSOFA_SCREEN` | Bedside sepsis *screen* positive | Warning |
| `SOFA_WARNING` / `SOFA_SEPSIS` | Organ dysfunction rising / sepsis pathway | Warning / Critical |
| `RAPID_DETERIORATION` | Fast adverse vital trend | Critical |

### Scoring cheat sheet

| Score | Range / rule | Action cue |
|-------|--------------|------------|
| NEWS2 0–4 | Low | Routine monitoring |
| NEWS2 5–6 or any param = 3 | Medium | Urgent review |
| NEWS2 ≥ 7 | High | Emergency response pathway |
| qSOFA ≥ 2 | Screen positive | Consider infection + SOFA labs |
| SOFA Δ ≥ 2 | Organ dysfunction rise | Sepsis recognition + hour-1 bundle |
| GCS ≤ 8 | Severe | Airway/neuro emergency posture |

---

## 10. Important Caveats for Evaluators

Please keep these boundaries in mind when judging fitness for clinical use:

1. **Decision support, not an EHR** — charting, billing, and full order workflows remain in hospital systems of record.
2. **Evaluation / prototype posture** — the platform is used for clinician feedback studies and technical demonstration; local regulatory clearance, validation studies, and hospital integration work are required before production patient-care claims.
3. **Bundle orders are tracked in VigilCare** — they are not automatically a live link to your pharmacy robot unless integrated.
4. **Escalation is a workflow signal** — the product models acknowledgment timeouts and escalated status; connecting to a specific enterprise paging vendor is an integration step.
5. **MEWS is not currently implemented** — NEWS2 is the general early-warning engine in use.
6. **SIRS-based sepsis logic was removed** in favor of **Sepsis-3** (qSOFA screen + SOFA delta).

---

## Related clinician documents

| Document | Audience |
|----------|----------|
| [Clinical Testing Guide](clinical-testing-guide.md) | Hands-on alert review sessions for doctors and nurses |
| [Dashboard Guide](dashboard-guide.md) | Screen-by-screen dashboard reference |
| [Dashboard Gap Analysis](dashboard-gap-analysis.md) | Known clinical UX gaps and completed improvements |
| [Partner Brief](VigilCare-Partner-Brief.md) | Resilience / ward continuity narrative |

---

*VigilCare Clinical — Physician Overview. Intended as an introductory briefing for clinicians evaluating the platform for workflow fit, patient safety value, and decision-support quality.*
