feature: Simulator Scenarios + Clinical Validation: SOFA/GCS

2026-06-21 04:55:39 +08:00
parent bf46e6554a
commit 3638dd0669
39 changed files with 1619 additions and 213 deletions
@@ -0,0 +1,3 @@
+public record GcsResponse(
+    int EyeScore, int VerbalScore, int MotorScore,
+    int TotalScore, string Classification, DateTimeOffset CalculatedAt);
@@ -0,0 +1 @@
+public record QsofaResponse(int ActiveCriteria);
@@ -0,0 +1,7 @@
+public record SofaResponse(
+    int TotalScore,
+    int RespiratoryScore, int CoagulationScore, int LiverScore,
+    int CardiovascularScore, int CnsScore, int RenalScore,
+    bool IsBaseline, int? DeltaFromBaseline,
+    SofaStalenessResponse? Staleness,
+    DateTimeOffset CalculatedAt);
@@ -0,0 +1,4 @@
+public record SofaStalenessResponse(
+    IReadOnlyList<string> StaleComponents,
+    IReadOnlyList<string> MissingComponents,
+    bool UsedSpO2Fallback);
@@ -119,4 +119,28 @@ public class VigilCareApiClient
            .ReadFromJsonAsync<ApiResponse<SepsisBundleResponse>>();
        return envelope?.Data;
    }
+
+    public async Task<GcsResponse?> GetCurrentGcsAsync(Guid encounterId)
+    {
+        var response = await _http.GetAsync($"/api/v1/encounters/{encounterId}/gcs");
+        if (!response.IsSuccessStatusCode) return null;
+        var envelope = await response.Content.ReadFromJsonAsync<ApiResponse<GcsResponse>>();
+        return envelope?.Data;
+    }
+
+    public async Task<SofaResponse?> GetCurrentSofaAsync(Guid encounterId)
+    {
+        var response = await _http.GetAsync($"/api/v1/encounters/{encounterId}/sofa");
+        if (!response.IsSuccessStatusCode) return null;
+        var envelope = await response.Content.ReadFromJsonAsync<ApiResponse<SofaResponse>>();
+        return envelope?.Data;
+    }
+
+    public async Task<QsofaResponse?> GetCurrentQsofaAsync(Guid encounterId)
+    {
+        var response = await _http.GetAsync($"/api/v1/encounters/{encounterId}/qsofa/current");
+        if (!response.IsSuccessStatusCode) return null;
+        var envelope = await response.Content.ReadFromJsonAsync<ApiResponse<QsofaResponse>>();
+        return envelope?.Data;
+    }
 }
@@ -71,6 +71,22 @@ public static class SimulatorConsole
            AnsiConsole.MarkupLine(
                $"[cyan][[{simTime}]][/] NEWS2 = {poll.News2.TotalScore} ({poll.News2.RiskLevel})");

+        if (poll.Gcs is not null)
+            AnsiConsole.MarkupLine(
+                $"[cyan][[{simTime}]][/] GCS = {poll.Gcs.TotalScore}/15 ({poll.Gcs.Classification}) " +
+                $"E{poll.Gcs.EyeScore} V{poll.Gcs.VerbalScore} M{poll.Gcs.MotorScore}");
+
+        if (poll.Sofa is not null)
+        {
+            var delta = poll.Sofa.DeltaFromBaseline is int d ? $" Δ+{d}" : "";
+            AnsiConsole.MarkupLine(
+                $"[cyan][[{simTime}]][/] SOFA = {poll.Sofa.TotalScore}/24{delta}");
+        }
+
+        if (poll.Qsofa is not null)
+            AnsiConsole.MarkupLine(
+                $"[cyan][[{simTime}]][/] qSOFA screen = {poll.Qsofa.ActiveCriteria}/3");
+
        foreach (var alert in poll.NewAlerts)
            AnsiConsole.MarkupLine(
                $"[red][[{simTime}]][/] ALERT {alert.AlertType} ({alert.Severity})");
@@ -78,6 +94,7 @@ public static class SimulatorConsole
        if (poll.SepsisBundle is not null)
            AnsiConsole.MarkupLine(
                $"[cyan][[{simTime}]][/] SEPSIS BUNDLE {poll.SepsisBundle.ComplianceStatus} " +
-                $"({poll.SepsisBundle.ElementsCompleted}/4)");
+                $"({poll.SepsisBundle.ElementsCompleted}/4) " +
+                $"trigger={poll.SepsisBundle.TriggeringAlertType}");
    }
 }
@@ -8,13 +8,16 @@ public class ApiPoller
    public async Task PollAndDisplayAsync(Guid encounterId, string simTime)
    {
        var news2 = await _client.GetCurrentNews2Async(encounterId);
+        var gcs = await _client.GetCurrentGcsAsync(encounterId);
+        var sofa = await _client.GetCurrentSofaAsync(encounterId);
+        var qsofa = await _client.GetCurrentQsofaAsync(encounterId);

        var allAlerts = await _client.GetAlertsAsync(encounterId);
        var newAlerts = allAlerts.Where(a => _seenAlertIds.Add(a.Id)).ToList();

        var bundle = await _client.GetSepsisBundleAsync(encounterId);

-        var result = new PollResult(news2, newAlerts, bundle);
+        var result = new PollResult(news2, gcs, sofa, qsofa, newAlerts, bundle);
        SimulatorConsole.PollResults(simTime, result);
    }
 }
@@ -1,4 +1,7 @@
 public record PollResult(
    News2Response? News2,
-    List<AlertResponse> NewAlerts,
+    GcsResponse? Gcs,
+    SofaResponse? Sofa,
+    QsofaResponse? Qsofa,
+    IReadOnlyList<AlertResponse> NewAlerts,
    SepsisBundleResponse? SepsisBundle);
@@ -99,6 +99,36 @@
        "source": "Manual"
      }
    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": {
+        "code": "GCS_EYE",
+        "value": 4,
+        "unit": "score",
+        "source": "Manual"
+      }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": {
+        "code": "GCS_VERBAL",
+        "value": 5,
+        "unit": "score",
+        "source": "Manual"
+      }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": {
+        "code": "GCS_MOTOR",
+        "value": 6,
+        "unit": "score",
+        "source": "Manual"
+      }
+    },
    {
      "offsetMinutes": 15,
      "type": "observation",
@@ -101,6 +101,36 @@
        "source": "Manual"
      }
    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": {
+        "code": "GCS_EYE",
+        "value": 4,
+        "unit": "score",
+        "source": "Manual"
+      }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": {
+        "code": "GCS_VERBAL",
+        "value": 4,
+        "unit": "score",
+        "source": "Manual"
+      }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": {
+        "code": "GCS_MOTOR",
+        "value": 6,
+        "unit": "score",
+        "source": "Manual"
+      }
+    },
    {
      "offsetMinutes": 2,
      "type": "observation",
@@ -110,6 +110,37 @@
      },
      "note": "Nasal cannula 2L/min started on arrival"
    },
+    {
+      "offsetMinutes": 1,
+      "type": "observation",
+      "data": {
+        "code": "GCS_EYE",
+        "value": 4,
+        "unit": "score",
+        "source": "Manual"
+      }
+    },
+    {
+      "offsetMinutes": 1,
+      "type": "observation",
+      "data": {
+        "code": "GCS_VERBAL",
+        "value": 4,
+        "unit": "score",
+        "source": "Manual"
+      }
+    },
+    {
+      "offsetMinutes": 1,
+      "type": "observation",
+      "data": {
+        "code": "GCS_MOTOR",
+        "value": 5,
+        "unit": "score",
+        "source": "Manual"
+      },
+      "note": "GCS 13 — sluggish, confused from hypothermia"
+    },
    {
      "offsetMinutes": 0,
      "type": "order",
@@ -56,6 +56,21 @@
      "type": "observation",
      "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "Manual" }
    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "GCS_EYE", "value": 4, "unit": "score", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "GCS_VERBAL", "value": 5, "unit": "score", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "GCS_MOTOR", "value": 6, "unit": "score", "source": "Manual" }
+    },

    {
      "offsetMinutes": 0,
@@ -0,0 +1,168 @@
+{
+  "scenario": {
+    "id": "neurological-decline-gcs-01",
+    "name": "Traumatic Brain Injury — Progressive GCS Decline",
+    "description": "Post-trauma patient with initial GCS 14 (E4V4M6). Over 3 hours, GCS declines to 6. Triggers GCS_WARNING then GCS_CRITICAL. Vitals remain stable — neuro-specific deterioration, not sepsis.",
+    "durationMinutes": 180,
+    "tags": ["gcs", "neurological", "no-sepsis", "news2"]
+  },
+  "patient": {
+    "firstName": "David",
+    "lastName": "Okonkwo",
+    "dateOfBirth": "1981-07-22",
+    "gender": "Male"
+  },
+  "encounter": {
+    "department": "Icu",
+    "encounterType": "Inpatient",
+    "attendingPhysician": "Dr. Amara Singh",
+    "roomBed": "ICU-1A-3",
+    "admissionReason": "TBI — motor vehicle collision, GCS 14 on arrival"
+  },
+  "events": [
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "HEART_RATE", "value": 72, "unit": "bpm", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "RESP_RATE", "value": 16, "unit": "/min", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "SYSTOLIC_BP", "value": 135, "unit": "mmHg", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "DIASTOLIC_BP", "value": 82, "unit": "mmHg", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "TEMP_C", "value": 36.9, "unit": "°C", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "SPO2", "value": 99, "unit": "%", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "SUPPLEMENTAL_O2", "value": 0, "unit": "flag", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "GCS_EYE", "value": 4, "unit": "score", "source": "Manual" },
+      "note": "GCS 14 — confused speech"
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "GCS_VERBAL", "value": 4, "unit": "score", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "GCS_MOTOR", "value": 6, "unit": "score", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 60,
+      "type": "observation",
+      "data": { "code": "GCS_EYE", "value": 3, "unit": "score", "source": "Manual" },
+      "note": "GCS 12 → GCS_WARNING"
+    },
+    {
+      "offsetMinutes": 60,
+      "type": "observation",
+      "data": { "code": "GCS_VERBAL", "value": 3, "unit": "score", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 60,
+      "type": "observation",
+      "data": { "code": "GCS_MOTOR", "value": 6, "unit": "score", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 60,
+      "type": "observation",
+      "data": { "code": "HEART_RATE", "value": 68, "unit": "bpm", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 60,
+      "type": "observation",
+      "data": { "code": "SYSTOLIC_BP", "value": 142, "unit": "mmHg", "source": "Device" },
+      "note": "Cushing response — HTN with bradycardia developing"
+    },
+    {
+      "offsetMinutes": 120,
+      "type": "observation",
+      "data": { "code": "GCS_EYE", "value": 2, "unit": "score", "source": "Manual" },
+      "note": "GCS 9 — still GCS_WARNING band"
+    },
+    {
+      "offsetMinutes": 120,
+      "type": "observation",
+      "data": { "code": "GCS_VERBAL", "value": 3, "unit": "score", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 120,
+      "type": "observation",
+      "data": { "code": "GCS_MOTOR", "value": 4, "unit": "score", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 120,
+      "type": "observation",
+      "data": { "code": "HEART_RATE", "value": 58, "unit": "bpm", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 120,
+      "type": "observation",
+      "data": { "code": "SYSTOLIC_BP", "value": 168, "unit": "mmHg", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 150,
+      "type": "observation",
+      "data": { "code": "GCS_EYE", "value": 1, "unit": "score", "source": "Manual" },
+      "note": "GCS 6 → GCS_CRITICAL"
+    },
+    {
+      "offsetMinutes": 150,
+      "type": "observation",
+      "data": { "code": "GCS_VERBAL", "value": 2, "unit": "score", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 150,
+      "type": "observation",
+      "data": { "code": "GCS_MOTOR", "value": 3, "unit": "score", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 155,
+      "type": "order",
+      "data": {
+        "orderType": "Imaging",
+        "orderCode": "CT_HEAD",
+        "description": "STAT CT head — GCS decline from 14 to 6",
+        "orderedBy": "Dr. Amara Singh"
+      }
+    }
+  ],
+  "expectedOutcomes": [
+    {
+      "afterOffsetMinutes": 60,
+      "type": "alert",
+      "alertType": "GCS_WARNING",
+      "description": "GCS 12 in 9–12 band"
+    },
+    {
+      "afterOffsetMinutes": 150,
+      "type": "alert",
+      "alertType": "GCS_CRITICAL",
+      "description": "GCS 6 ≤ 8"
+    }
+  ]
+}
@@ -110,6 +110,36 @@
      },
      "note": "Nasal cannula 2L/min \u2014 standard post-op order"
    },
+    {
+      "offsetMinutes": 1,
+      "type": "observation",
+      "data": {
+        "code": "GCS_EYE",
+        "value": 4,
+        "unit": "score",
+        "source": "Manual"
+      }
+    },
+    {
+      "offsetMinutes": 1,
+      "type": "observation",
+      "data": {
+        "code": "GCS_VERBAL",
+        "value": 5,
+        "unit": "score",
+        "source": "Manual"
+      }
+    },
+    {
+      "offsetMinutes": 1,
+      "type": "observation",
+      "data": {
+        "code": "GCS_MOTOR",
+        "value": 6,
+        "unit": "score",
+        "source": "Manual"
+      }
+    },
    {
      "offsetMinutes": 20,
      "type": "observation",
@@ -718,6 +748,37 @@
    {
      "offsetMinutes": 120,
      "type": "observation",
+      "data": {
+        "code": "GCS_EYE",
+        "value": 3,
+        "unit": "score",
+        "source": "Manual"
+      },
+      "note": "GCS 11 \u2014 hemorrhagic shock, declining consciousness"
+    },
+    {
+      "offsetMinutes": 120,
+      "type": "observation",
+      "data": {
+        "code": "GCS_VERBAL",
+        "value": 4,
+        "unit": "score",
+        "source": "Manual"
+      }
+    },
+    {
+      "offsetMinutes": 120,
+      "type": "observation",
+      "data": {
+        "code": "GCS_MOTOR",
+        "value": 4,
+        "unit": "score",
+        "source": "Manual"
+      }
+    },
+    {
+      "offsetMinutes": 121,
+      "type": "observation",
      "data": {
        "code": "SUPPLEMENTAL_O2",
        "value": 1,
@@ -726,7 +787,7 @@
      }
    },
    {
-      "offsetMinutes": 120,
+      "offsetMinutes": 121,
      "type": "observation",
      "data": {
        "code": "LACTATE_MMOL_L",
@@ -98,6 +98,36 @@
        "source": "Manual"
      }
    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": {
+        "code": "GCS_EYE",
+        "value": 4,
+        "unit": "score",
+        "source": "Manual"
+      }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": {
+        "code": "GCS_VERBAL",
+        "value": 5,
+        "unit": "score",
+        "source": "Manual"
+      }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": {
+        "code": "GCS_MOTOR",
+        "value": 6,
+        "unit": "score",
+        "source": "Manual"
+      }
+    },
    {
      "offsetMinutes": 0,
      "type": "order",
@@ -0,0 +1,263 @@
+{
+  "scenario": {
+    "id": "sepsis-sofa-progression-01",
+    "name": "Pneumonia → Multi-Organ Dysfunction (SOFA Pathway)",
+    "description": "ICU patient with community-acquired pneumonia. Initial SOFA baseline ~2. Over 4 hours, respiratory failure, thrombocytopenia, and renal impairment develop. qSOFA screen fires early; SOFA delta ≥ 2 triggers sepsis bundle. GCS remains 15 until late decline to 13.",
+    "durationMinutes": 240,
+    "tags": ["sofa", "sepsis", "multi-organ", "gcs", "qsofa-screen"]
+  },
+  "patient": {
+    "firstName": "Margaret",
+    "lastName": "Torres",
+    "dateOfBirth": "1954-03-18",
+    "gender": "Female"
+  },
+  "encounter": {
+    "department": "Icu",
+    "encounterType": "Inpatient",
+    "attendingPhysician": "Dr. Elena Vasquez",
+    "roomBed": "ICU-2A-6",
+    "admissionReason": "Community-acquired pneumonia, worsening dyspnea"
+  },
+  "events": [
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "HEART_RATE", "value": 88, "unit": "bpm", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "RESP_RATE", "value": 18, "unit": "/min", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "SYSTOLIC_BP", "value": 128, "unit": "mmHg", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "DIASTOLIC_BP", "value": 78, "unit": "mmHg", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "TEMP_C", "value": 38.2, "unit": "°C", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "SPO2", "value": 94, "unit": "%", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "SUPPLEMENTAL_O2", "value": 1, "unit": "flag", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "GCS_EYE", "value": 4, "unit": "score", "source": "Manual" },
+      "note": "Baseline GCS 15 — fully alert"
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "GCS_VERBAL", "value": 5, "unit": "score", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "GCS_MOTOR", "value": 6, "unit": "score", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 5,
+      "type": "observation",
+      "data": { "code": "PAO2_MMHG", "value": 85, "unit": "mmHg", "source": "Lab" },
+      "note": "ABG baseline — P/F ~283 at FiO2 30%"
+    },
+    {
+      "offsetMinutes": 5,
+      "type": "observation",
+      "data": { "code": "FIO2_PCT", "value": 30, "unit": "%", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 5,
+      "type": "observation",
+      "data": { "code": "PLATELET_K_UL", "value": 185, "unit": "k/µL", "source": "Lab" }
+    },
+    {
+      "offsetMinutes": 5,
+      "type": "observation",
+      "data": { "code": "BILIRUBIN_MG_DL", "value": 0.9, "unit": "mg/dL", "source": "Lab" }
+    },
+    {
+      "offsetMinutes": 5,
+      "type": "observation",
+      "data": { "code": "CREATININE_MG_DL", "value": 1.0, "unit": "mg/dL", "source": "Lab" }
+    },
+    {
+      "offsetMinutes": 5,
+      "type": "observation",
+      "data": { "code": "LACTATE_MMOL_L", "value": 1.8, "unit": "mmol/L", "source": "Lab" }
+    },
+    {
+      "offsetMinutes": 60,
+      "type": "observation",
+      "data": { "code": "HEART_RATE", "value": 102, "unit": "bpm", "source": "Device" },
+      "note": "Mild tachycardia; qSOFA RR ≥ 22"
+    },
+    {
+      "offsetMinutes": 60,
+      "type": "observation",
+      "data": { "code": "RESP_RATE", "value": 24, "unit": "/min", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 60,
+      "type": "observation",
+      "data": { "code": "SYSTOLIC_BP", "value": 105, "unit": "mmHg", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 60,
+      "type": "observation",
+      "data": { "code": "TEMP_C", "value": 38.9, "unit": "°C", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 120,
+      "type": "observation",
+      "data": { "code": "RESP_RATE", "value": 28, "unit": "/min", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 120,
+      "type": "observation",
+      "data": { "code": "SYSTOLIC_BP", "value": 92, "unit": "mmHg", "source": "Device" },
+      "note": "SBP ≤ 100 → qSOFA ≥ 2 → QSOFA_SCREEN"
+    },
+    {
+      "offsetMinutes": 120,
+      "type": "observation",
+      "data": { "code": "DIASTOLIC_BP", "value": 58, "unit": "mmHg", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 120,
+      "type": "observation",
+      "data": { "code": "SPO2", "value": 89, "unit": "%", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 125,
+      "type": "observation",
+      "data": { "code": "PAO2_MMHG", "value": 62, "unit": "mmHg", "source": "Lab" },
+      "note": "Repeat ABG — P/F 155 at FiO2 40% → SOFA Resp 2"
+    },
+    {
+      "offsetMinutes": 125,
+      "type": "observation",
+      "data": { "code": "FIO2_PCT", "value": 40, "unit": "%", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 125,
+      "type": "observation",
+      "data": { "code": "PLATELET_K_UL", "value": 88, "unit": "k/µL", "source": "Lab" },
+      "note": "Thrombocytopenia → SOFA Coag 1"
+    },
+    {
+      "offsetMinutes": 125,
+      "type": "observation",
+      "data": { "code": "CREATININE_MG_DL", "value": 2.3, "unit": "mg/dL", "source": "Lab" },
+      "note": "AKI → SOFA Renal 2"
+    },
+    {
+      "offsetMinutes": 125,
+      "type": "observation",
+      "data": { "code": "LACTATE_MMOL_L", "value": 3.1, "unit": "mmol/L", "source": "Lab" }
+    },
+    {
+      "offsetMinutes": 130,
+      "type": "medication",
+      "data": {
+        "drugName": "Norepinephrine",
+        "dose": 0.05,
+        "doseUnit": "mcg/kg/min",
+        "route": "IV",
+        "administeredBy": "RN-Torres"
+      },
+      "note": "Vasopressor → SOFA CV 3; delta ≥ 2 → SOFA_SEPSIS + bundle"
+    },
+    {
+      "offsetMinutes": 180,
+      "type": "observation",
+      "data": { "code": "PAO2_MMHG", "value": 55, "unit": "mmHg", "source": "Lab" }
+    },
+    {
+      "offsetMinutes": 180,
+      "type": "observation",
+      "data": { "code": "FIO2_PCT", "value": 60, "unit": "%", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 180,
+      "type": "observation",
+      "data": { "code": "PLATELET_K_UL", "value": 42, "unit": "k/µL", "source": "Lab" }
+    },
+    {
+      "offsetMinutes": 180,
+      "type": "observation",
+      "data": { "code": "CREATININE_MG_DL", "value": 3.8, "unit": "mg/dL", "source": "Lab" }
+    },
+    {
+      "offsetMinutes": 200,
+      "type": "observation",
+      "data": { "code": "GCS_EYE", "value": 3, "unit": "score", "source": "Manual" },
+      "note": "GCS 13 — SOFA CNS 1"
+    },
+    {
+      "offsetMinutes": 200,
+      "type": "observation",
+      "data": { "code": "GCS_VERBAL", "value": 4, "unit": "score", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 200,
+      "type": "observation",
+      "data": { "code": "GCS_MOTOR", "value": 6, "unit": "score", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 210,
+      "type": "order",
+      "data": {
+        "orderType": "Lab",
+        "orderCode": "BLOOD_CULTURE",
+        "description": "Blood cultures x2 — sepsis workup",
+        "orderedBy": "Dr. Elena Vasquez"
+      }
+    },
+    {
+      "offsetMinutes": 210,
+      "type": "order",
+      "data": {
+        "orderType": "Lab",
+        "orderCode": "SERUM_LACTATE",
+        "description": "Repeat lactate",
+        "orderedBy": "Dr. Elena Vasquez"
+      }
+    }
+  ],
+  "expectedOutcomes": [
+    {
+      "afterOffsetMinutes": 120,
+      "type": "alert",
+      "alertType": "QSOFA_SCREEN",
+      "description": "qSOFA ≥ 2 — bedside screen positive, recommend SOFA labs"
+    },
+    {
+      "afterOffsetMinutes": 130,
+      "type": "alert",
+      "alertType": "SOFA_SEPSIS",
+      "description": "SOFA delta ≥ 2 from baseline after labs + vasopressor"
+    },
+    {
+      "afterOffsetMinutes": 130,
+      "type": "bundle",
+      "description": "Sepsis bundle auto-created; triggeringAlertType = SOFA_SEPSIS"
+    }
+  ]
+}
@@ -0,0 +1,166 @@
+{
+  "scenario": {
+    "id": "sofa-partial-spo2-fallback-01",
+    "name": "Ward Patient — Partial SOFA with SpO₂/FiO₂ Proxy",
+    "description": "General medicine patient with worsening pneumonia. No ABG — SpO₂/FiO₂ used for respiratory SOFA. Partial scoring when labs missing; carry-forward and staleness flags when data ages.",
+    "durationMinutes": 360,
+    "tags": ["sofa", "partial-scoring", "spo2-fallback", "carry-forward", "ward"]
+  },
+  "patient": {
+    "firstName": "Priya",
+    "lastName": "Sharma",
+    "dateOfBirth": "1970-01-14",
+    "gender": "Female"
+  },
+  "encounter": {
+    "department": "GeneralMedicine",
+    "encounterType": "Inpatient",
+    "attendingPhysician": "Dr. Noah Chen",
+    "roomBed": "GM-8B-2",
+    "admissionReason": "Worsening pneumonia, transferred from ED"
+  },
+  "events": [
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "HEART_RATE", "value": 92, "unit": "bpm", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "RESP_RATE", "value": 20, "unit": "/min", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "SYSTOLIC_BP", "value": 118, "unit": "mmHg", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "DIASTOLIC_BP", "value": 72, "unit": "mmHg", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "SPO2", "value": 93, "unit": "%", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "FIO2_PCT", "value": 28, "unit": "%", "source": "Manual" },
+      "note": "Nasal cannula 2L — S/F ~332, SOFA Resp 0"
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "SUPPLEMENTAL_O2", "value": 1, "unit": "flag", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "TEMP_C", "value": 38.5, "unit": "°C", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "GCS_EYE", "value": 4, "unit": "score", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "GCS_VERBAL", "value": 5, "unit": "score", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": { "code": "GCS_MOTOR", "value": 6, "unit": "score", "source": "Manual" }
+    },
+    {
+      "offsetMinutes": 30,
+      "type": "observation",
+      "data": { "code": "CREATININE_MG_DL", "value": 1.1, "unit": "mg/dL", "source": "Lab" },
+      "note": "Partial SOFA — no platelets/bilirubin yet"
+    },
+    {
+      "offsetMinutes": 120,
+      "type": "observation",
+      "data": { "code": "PLATELET_K_UL", "value": 165, "unit": "k/µL", "source": "Lab" }
+    },
+    {
+      "offsetMinutes": 120,
+      "type": "observation",
+      "data": { "code": "BILIRUBIN_MG_DL", "value": 0.8, "unit": "mg/dL", "source": "Lab" },
+      "note": "Baseline SOFA now more complete"
+    },
+    {
+      "offsetMinutes": 180,
+      "type": "observation",
+      "data": { "code": "SPO2", "value": 88, "unit": "%", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 180,
+      "type": "observation",
+      "data": { "code": "FIO2_PCT", "value": 40, "unit": "%", "source": "Manual" },
+      "note": "S/F 220 → SOFA Resp ~1; usedSpO2Fallback true"
+    },
+    {
+      "offsetMinutes": 180,
+      "type": "observation",
+      "data": { "code": "RESP_RATE", "value": 26, "unit": "/min", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 240,
+      "type": "observation",
+      "data": { "code": "SPO2", "value": 84, "unit": "%", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 240,
+      "type": "observation",
+      "data": { "code": "FIO2_PCT", "value": 60, "unit": "%", "source": "Manual" },
+      "note": "S/F 140 → SOFA Resp 2"
+    },
+    {
+      "offsetMinutes": 240,
+      "type": "observation",
+      "data": { "code": "CREATININE_MG_DL", "value": 1.9, "unit": "mg/dL", "source": "Lab" }
+    },
+    {
+      "offsetMinutes": 240,
+      "type": "observation",
+      "data": { "code": "PLATELET_K_UL", "value": 110, "unit": "k/µL", "source": "Lab" },
+      "note": "SOFA Coag 1"
+    },
+    {
+      "offsetMinutes": 300,
+      "type": "observation",
+      "data": { "code": "SYSTOLIC_BP", "value": 88, "unit": "mmHg", "source": "Device" }
+    },
+    {
+      "offsetMinutes": 300,
+      "type": "observation",
+      "data": { "code": "DIASTOLIC_BP", "value": 52, "unit": "mmHg", "source": "Device" },
+      "note": "MAP 64 → SOFA CV 1"
+    },
+    {
+      "offsetMinutes": 300,
+      "type": "observation",
+      "data": { "code": "CREATININE_MG_DL", "value": 2.5, "unit": "mg/dL", "source": "Lab" },
+      "note": "SOFA Renal 2; delta may reach ≥ 2"
+    }
+  ],
+  "expectedOutcomes": [
+    {
+      "afterOffsetMinutes": 180,
+      "type": "score",
+      "scoreType": "SOFA",
+      "description": "SOFA computed with usedSpO2Fallback in staleness flags"
+    },
+    {
+      "afterOffsetMinutes": 300,
+      "type": "alert",
+      "alertType": "SOFA_SEPSIS",
+      "description": "Multi-organ decline — delta ≥ 2 from baseline"
+    }
+  ]
+}
@@ -99,6 +99,36 @@
        "source": "Manual"
      }
    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": {
+        "code": "GCS_EYE",
+        "value": 4,
+        "unit": "score",
+        "source": "Manual"
+      }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": {
+        "code": "GCS_VERBAL",
+        "value": 5,
+        "unit": "score",
+        "source": "Manual"
+      }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": {
+        "code": "GCS_MOTOR",
+        "value": 6,
+        "unit": "score",
+        "source": "Manual"
+      }
+    },
    {
      "offsetMinutes": 30,
      "type": "observation",
@@ -2,7 +2,7 @@
  "scenario": {
    "id": "uti-sepsis-elderly-01",
    "name": "UTI Progressing to Sepsis in Elderly Patient",
-    "description": "72-year-old female presenting with UTI symptoms who deteriorates into sepsis over 4 hours, triggering SIRS, qSOFA, and NEWS2 alerts with sepsis bundle compliance.",
+    "description": "72-year-old female with UTI progressing to sepsis over 4 hours. qSOFA screen fires first; SOFA delta \u2265 2 triggers sepsis bundle. NEWS2 and bundle compliance still exercised.",
    "durationMinutes": 240,
    "tags": [
      "sepsis",
@@ -98,6 +98,36 @@
        "source": "Manual"
      }
    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": {
+        "code": "GCS_EYE",
+        "value": 4,
+        "unit": "score",
+        "source": "Manual"
+      }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": {
+        "code": "GCS_VERBAL",
+        "value": 4,
+        "unit": "score",
+        "source": "Manual"
+      }
+    },
+    {
+      "offsetMinutes": 0,
+      "type": "observation",
+      "data": {
+        "code": "GCS_MOTOR",
+        "value": 6,
+        "unit": "score",
+        "source": "Manual"
+      }
+    },
    {
      "offsetMinutes": 20,
      "type": "observation",
@@ -281,6 +311,56 @@
        "source": "Lab"
      }
    },
+    {
+      "offsetMinutes": 45,
+      "type": "observation",
+      "data": {
+        "code": "PAO2_MMHG",
+        "value": 92,
+        "unit": "mmHg",
+        "source": "Lab"
+      }
+    },
+    {
+      "offsetMinutes": 45,
+      "type": "observation",
+      "data": {
+        "code": "FIO2_PCT",
+        "value": 28,
+        "unit": "%",
+        "source": "Manual"
+      }
+    },
+    {
+      "offsetMinutes": 45,
+      "type": "observation",
+      "data": {
+        "code": "PLATELET_K_UL",
+        "value": 210,
+        "unit": "k/\u00b5L",
+        "source": "Lab"
+      }
+    },
+    {
+      "offsetMinutes": 45,
+      "type": "observation",
+      "data": {
+        "code": "BILIRUBIN_MG_DL",
+        "value": 0.7,
+        "unit": "mg/dL",
+        "source": "Lab"
+      }
+    },
+    {
+      "offsetMinutes": 45,
+      "type": "observation",
+      "data": {
+        "code": "CREATININE_MG_DL",
+        "value": 1.0,
+        "unit": "mg/dL",
+        "source": "Lab"
+      }
+    },
    {
      "offsetMinutes": 40,
      "type": "order",
@@ -450,7 +530,7 @@
        "unit": "bpm",
        "source": "Device"
      },
-      "note": "SIRS criteria met: Temp >38.3 + HR >90 \u2192 SEPSIS_WARNING"
+      "note": "Temp >38.3 + HR >90 \u2014 early sepsis physiology"
    },
    {
      "offsetMinutes": 90,
@@ -627,7 +707,7 @@
        "unit": "bpm",
        "source": "Device"
      },
-      "note": "NEWS2 = 6, SIRS 3 of 4 criteria met (Temp, HR, RR)"
+      "note": "NEWS2 = 6, continued deterioration"
    },
    {
      "offsetMinutes": 120,
@@ -698,7 +778,7 @@
        "unit": "\u00d710\u00b3/\u00b5L",
        "source": "Lab"
      },
-      "note": "Repeat labs \u2014 WBC elevated, lactate rising, SIRS 4/4"
+      "note": "Repeat labs \u2014 WBC elevated, lactate rising"
    },
    {
      "offsetMinutes": 120,
@@ -730,6 +810,48 @@
        "source": "Lab"
      }
    },
+    {
+      "offsetMinutes": 125,
+      "type": "observation",
+      "data": {
+        "code": "PAO2_MMHG",
+        "value": 68,
+        "unit": "mmHg",
+        "source": "Lab"
+      },
+      "note": "Worsening gas exchange \u2014 SOFA Resp \u2191"
+    },
+    {
+      "offsetMinutes": 125,
+      "type": "observation",
+      "data": {
+        "code": "FIO2_PCT",
+        "value": 40,
+        "unit": "%",
+        "source": "Manual"
+      }
+    },
+    {
+      "offsetMinutes": 125,
+      "type": "observation",
+      "data": {
+        "code": "PLATELET_K_UL",
+        "value": 95,
+        "unit": "k/\u00b5L",
+        "source": "Lab"
+      }
+    },
+    {
+      "offsetMinutes": 125,
+      "type": "observation",
+      "data": {
+        "code": "CREATININE_MG_DL",
+        "value": 2.1,
+        "unit": "mg/dL",
+        "source": "Lab"
+      },
+      "note": "AKI \u2014 SOFA Renal \u2191; delta \u2265 2 \u2192 SOFA_SEPSIS"
+    },
    {
      "offsetMinutes": 125,
      "type": "medication",
@@ -1308,46 +1430,34 @@
      "description": "HR enters warning range (91 bpm)"
    },
    {
-      "afterOffsetMinutes": 90,
+      "afterOffsetMinutes": 105,
      "type": "alert",
-      "alertType": "SEPSIS_WARNING",
-      "description": "SIRS criteria met: Temp 38.4\u00b0C (>38.3) + HR 96 (>90) = 2 of 4"
+      "alertType": "QSOFA_SCREEN",
+      "description": "qSOFA \u2265 2 \u2014 screen positive, recommend SOFA labs"
    },
    {
-      "afterOffsetMinutes": 90,
+      "afterOffsetMinutes": 125,
+      "type": "alert",
+      "alertType": "SOFA_SEPSIS",
+      "description": "SOFA delta \u2265 2 from baseline after repeat labs"
+    },
+    {
+      "afterOffsetMinutes": 125,
      "type": "bundle",
-      "description": "Sepsis bundle auto-created with 4 orders: blood cultures, serum lactate, broad-spectrum antibiotics, IV fluid resuscitation"
+      "description": "Sepsis bundle auto-created; triggeringAlertType = SOFA_SEPSIS"
    },
    {
      "afterOffsetMinutes": 105,
      "type": "score",
      "scoreType": "NEWS2",
      "expectedMinimum": 5,
-      "description": "NEWS2 reaches 5 (HR=1, RR=2, Temp=1, SpO2=1) \u2192 WARNING threshold"
+      "description": "NEWS2 reaches medium risk"
    },
    {
      "afterOffsetMinutes": 135,
      "type": "alert",
      "alertType": "NEWS2_EMERGENCY",
-      "description": "NEWS2 reaches 8 (HR=2, RR=2, SBP=1, Temp=2, SpO2=1) \u22657 \u2192 EMERGENCY"
-    },
-    {
-      "afterOffsetMinutes": 135,
-      "type": "score",
-      "scoreType": "NEWS2",
-      "expectedMinimum": 7,
-      "description": "NEWS2 \u22657 sustained through peak deterioration"
-    },
-    {
-      "afterOffsetMinutes": 150,
-      "type": "alert",
-      "alertType": "QSOFA_WARNING",
-      "description": "qSOFA 3/3: RR 24 (\u226522) + SBP 98 (\u2264100) + AVPU 1 (\u22651)"
-    },
-    {
-      "afterOffsetMinutes": 130,
-      "type": "bundle",
-      "description": "Sepsis bundle COMPLIANT \u2014 all 4 orders completed within 40 minutes (blood cultures T+92, lactate T+95, ceftriaxone T+125, IV fluids T+130)"
+      "description": "NEWS2 \u2265 7 at peak deterioration"
    }
  ]
 }
@@ -4,7 +4,12 @@ public static class ScenarioValidator
    {
        "HEART_RATE", "RESP_RATE", "SYSTOLIC_BP", "DIASTOLIC_BP",
        "TEMP_C", "SPO2", "AVPU", "SUPPLEMENTAL_O2",
-        "WBC_K_UL", "POTASSIUM_MEQ_L", "LACTATE_MMOL_L", "GLUCOSE_MG_DL"
+        "WBC_K_UL", "POTASSIUM_MEQ_L", "LACTATE_MMOL_L", "GLUCOSE_MG_DL",
+        // Phase 25 — GCS components
+        "GCS_EYE", "GCS_VERBAL", "GCS_MOTOR",
+        // Phase 26 — SOFA lab / respiratory inputs
+        "PAO2_MMHG", "FIO2_PCT", "PLATELET_K_UL",
+        "BILIRUBIN_MG_DL", "CREATININE_MG_DL", "URINE_OUTPUT_ML_H",
    };

    private static readonly HashSet<string> ValidSources = new()
@@ -67,15 +72,15 @@ public static class ScenarioValidator
        }

        var placedOrders = new HashSet<string>(StringComparer.OrdinalIgnoreCase);
-        double lastOffset = -1;
-        for (int i = 0; i < scenario.Events.Count; i++)
+        var indexedEvents = scenario.Events
+            .Select((evt, i) => (evt, i))
+            .OrderBy(x => x.evt.OffsetMinutes)
+            .ThenBy(x => x.i);
+
+        foreach (var (evt, i) in indexedEvents)
        {
-            var evt = scenario.Events[i];
            if (evt.OffsetMinutes < 0)
                errors.Add($"events[{i}]: offsetMinutes cannot be negative");
-            if (evt.OffsetMinutes < lastOffset)
-                errors.Add($"events[{i}]: offsetMinutes goes backwards ({evt.OffsetMinutes} < {lastOffset})");
-            lastOffset = evt.OffsetMinutes;

            if (!ValidEventTypes.Contains(evt.Type))
                errors.Add($"events[{i}]: unknown type '{evt.Type}'");
@@ -123,7 +128,7 @@ public static class ScenarioValidator
                {
                    errors.Add(
                        $"events[{i}]: order_result '{orderDescription}' has no matching prior 'order' event " +
-                        "(sepsis bundle orders are auto-created when SEPSIS_WARNING or QSOFA_WARNING fires)");
+                        "(sepsis bundle orders are auto-created when SOFA_SEPSIS or QSOFA_SCREEN fires)");
                }
            }
        }
@@ -63,6 +63,20 @@
          "description": { "type": "string" }
        }
      }
+    },
+    "observationCodes": {
+      "type": "array",
+      "description": "Valid observation codes",
+      "items": {
+        "enum": [
+          "HEART_RATE", "RESP_RATE", "SYSTOLIC_BP", "DIASTOLIC_BP",
+          "TEMP_C", "SPO2", "AVPU", "SUPPLEMENTAL_O2",
+          "WBC_K_UL", "POTASSIUM_MEQ_L", "LACTATE_MMOL_L", "GLUCOSE_MG_DL",
+          "GCS_EYE", "GCS_VERBAL", "GCS_MOTOR",
+          "PAO2_MMHG", "FIO2_PCT", "PLATELET_K_UL",
+          "BILIRUBIN_MG_DL", "CREATININE_MG_DL", "URINE_OUTPUT_ML_H"
+        ]
+      }
    }
  }
 }
@@ -5,7 +5,7 @@ public class AlertCreationGuardTests
    [Fact]
    public void CannotCreateNewSepsisWarning()
    {
-        var act = () => AlertCreationGuard.EnsureAllowed(AlertType.SepsisWarning);
+        var act = () => AlertCreationGuard.EnsureAllowed(AlertTypeExtensions.FromDbString("SEPSIS_WARNING"));
        act.Should().Throw<InvalidOperationException>()
            .WithMessage("*deprecated*");
    }
@@ -0,0 +1,112 @@
+using System.Text.Json;
+using FluentAssertions;
+using Microsoft.EntityFrameworkCore;
+using Microsoft.Extensions.DependencyInjection;
+using StackExchange.Redis;
+
+[Collection("Integration")]
+public class ClinicalRefactorEndToEndTests : IAsyncLifetime
+{
+    private readonly ApiFixture _fixture;
+    private readonly HttpClient _client;
+
+    public ClinicalRefactorEndToEndTests(ApiFixture fixture)
+    {
+        _fixture = fixture;
+        _client = fixture.CreateClient();
+    }
+
+    public async Task InitializeAsync()
+    {
+        using var scope = _fixture.Services.CreateScope();
+        var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();
+        await DbResetHelper.ResetAsync(db);
+
+        var redis = scope.ServiceProvider.GetRequiredService<IConnectionMultiplexer>();
+        await DataSeeder.SeedThresholdsOnlyAsync(db, redis);
+    }
+
+    public Task DisposeAsync() => Task.CompletedTask;
+
+    [Fact]
+    public async Task SofaProgressionScenario_EndToEnd()
+    {
+        var scenario = ScenarioReplayHelper.Load("sepsis-sofa-progression-01.json");
+        var (_, encounterId) = await ScenarioReplayHelper.ReplayObservationsAsync(_client, scenario);
+
+        await ScenarioReplayHelper.WaitForAlertTypeAsync(
+            _fixture.Services, encounterId, AlertType.QsofaScreen, TimeSpan.FromSeconds(30));
+
+        await ScenarioReplayHelper.WaitForAlertTypeAsync(
+            _fixture.Services, encounterId, AlertType.SofaSepsis, TimeSpan.FromSeconds(30));
+
+        using var scope = _fixture.Services.CreateScope();
+        var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();
+        var bundle = await db.SepsisBundles.SingleAsync(b => b.EncounterId == encounterId);
+        bundle.TriggeringAlertType.Should().Be("SOFA_SEPSIS");
+    }
+
+    [Fact]
+    public async Task GcsDeclineScenario_EndToEnd()
+    {
+        var scenario = ScenarioReplayHelper.Load("neurological-decline-gcs-01.json");
+        var (_, encounterId) = await ScenarioReplayHelper.ReplayObservationsAsync(_client, scenario);
+
+        await ScenarioReplayHelper.WaitForAlertTypeAsync(
+            _fixture.Services, encounterId, AlertType.GcsWarning, TimeSpan.FromSeconds(30));
+
+        await ScenarioReplayHelper.WaitForAlertTypeAsync(
+            _fixture.Services, encounterId, AlertType.GcsCritical, TimeSpan.FromSeconds(30));
+
+        await ScenarioReplayHelper.AssertNoAlertTypeAsync(
+            _fixture.Services, encounterId, AlertType.SofaSepsis, TimeSpan.FromSeconds(5));
+
+        await ScenarioReplayHelper.AssertNoAlertTypeAsync(
+            _fixture.Services, encounterId, AlertTypeExtensions.FromDbString("SEPSIS_WARNING"), TimeSpan.FromSeconds(1));
+    }
+
+    [Fact]
+    public async Task PartialSofaScenario_StalenessFlags()
+    {
+        var scenario = ScenarioReplayHelper.Load("sofa-partial-spo2-fallback-01.json");
+        var (_, encounterId) = await ScenarioReplayHelper.ReplayObservationsAsync(_client, scenario);
+
+        var sofa = await ScenarioReplayHelper.WaitForSofaScoreAsync(
+            _fixture.Services, encounterId, TimeSpan.FromSeconds(45));
+
+        sofa.StalenessFlags.Should().NotBeNullOrEmpty();
+        var flags = JsonSerializer.Deserialize<SofaStalenessFlags>(
+            sofa.StalenessFlags!,
+            new JsonSerializerOptions { PropertyNameCaseInsensitive = true });
+        flags!.UsedSpO2Fallback.Should().BeTrue("expected SpO2/FiO2 proxy for respiratory SOFA");
+    }
+
+    [Theory]
+    [InlineData("stable-baseline-01.json")]
+    [InlineData("cardiac-arrest-post-mi-01.json")]
+    [InlineData("post-op-hemorrhage-01.json")]
+    [InlineData("respiratory-failure-asthma-01.json")]
+    [InlineData("dka-electrolyte-01.json")]
+    [InlineData("medication-false-alarm-01.json")]
+    [InlineData("hypothermia-elderly-01.json")]
+    [InlineData("uti-sepsis-elderly-01.json")]
+    public void ExistingScenarios_ValidateWithoutErrors(string fileName)
+    {
+        var scenario = ScenarioReplayHelper.Load(fileName);
+        var errors = ScenarioValidator.Validate(scenario);
+        errors.Should().BeEmpty(string.Join("; ", errors));
+    }
+
+    [Fact]
+    public async Task UtiSepsisScenario_NowUsesSofa()
+    {
+        var scenario = ScenarioReplayHelper.Load("uti-sepsis-elderly-01.json");
+        var (_, encounterId) = await ScenarioReplayHelper.ReplayObservationsAsync(_client, scenario);
+
+        await ScenarioReplayHelper.WaitForAlertTypeAsync(
+            _fixture.Services, encounterId, AlertType.SofaSepsis, TimeSpan.FromSeconds(45));
+
+        await ScenarioReplayHelper.AssertNoAlertTypeAsync(
+            _fixture.Services, encounterId, AlertTypeExtensions.FromDbString("SEPSIS_WARNING"), TimeSpan.FromSeconds(5));
+    }
+}
@@ -0,0 +1,155 @@
+using System.Net.Http.Json;
+using System.Text.Json;
+using Microsoft.EntityFrameworkCore;
+using Microsoft.Extensions.DependencyInjection;
+
+public static class ScenarioReplayHelper
+{
+    private static readonly JsonSerializerOptions JsonOptions = new()
+    {
+        PropertyNameCaseInsensitive = true,
+    };
+
+    public static string ScenariosDirectory =>
+        Path.GetFullPath(Path.Combine(
+            AppContext.BaseDirectory,
+            "..", "..", "..", "..",
+            "VigilCare.Simulator", "Scenarios", "List"));
+
+    public static ScenarioFile Load(string fileName)
+    {
+        var path = Path.Combine(ScenariosDirectory, fileName);
+        var json = File.ReadAllText(path);
+        return JsonSerializer.Deserialize<ScenarioFile>(json, JsonOptions)
+            ?? throw new InvalidOperationException($"Failed to deserialize {path}");
+    }
+
+    public static async Task<(Guid PatientId, Guid EncounterId)> ReplayObservationsAsync(
+        HttpClient client,
+        ScenarioFile scenario,
+        CancellationToken ct = default)
+    {
+        var patientResp = await client.PostAsJsonAsync("/api/v1/patients", new
+        {
+            firstName = scenario.Patient.FirstName,
+            lastName = scenario.Patient.LastName,
+            dateOfBirth = scenario.Patient.DateOfBirth,
+            gender = scenario.Patient.Gender,
+        }, ct);
+        patientResp.EnsureSuccessStatusCode();
+        var patient = (await patientResp.Content.ReadFromJsonAsync<ApiEnvelope<PatientDto>>(ct))!.Data;
+
+        var encounterResp = await client.PostAsJsonAsync(
+            $"/api/v1/patients/{patient.Id}/encounters",
+            new
+            {
+                encounterType = scenario.Encounter.EncounterType,
+                department = scenario.Encounter.Department,
+                attendingPhysician = scenario.Encounter.AttendingPhysician,
+                roomBed = scenario.Encounter.RoomBed,
+                admissionReason = scenario.Encounter.AdmissionReason,
+            }, ct);
+        encounterResp.EnsureSuccessStatusCode();
+        var encounter = (await encounterResp.Content.ReadFromJsonAsync<ApiEnvelope<EncounterDto>>(ct))!.Data;
+
+        var start = DateTimeOffset.UtcNow;
+        foreach (var cluster in scenario.Events
+            .Where(e => e.Type == "observation")
+            .GroupBy(e => e.OffsetMinutes)
+            .OrderBy(g => g.Key))
+        {
+            var recordedAt = start.AddMinutes(cluster.Key);
+            var batch = cluster.Select(evt =>
+            {
+                var code = evt.Data.GetProperty("code").GetString()!;
+                var value = evt.Data.GetProperty("value").GetDecimal();
+                var unit = evt.Data.GetProperty("unit").GetString()!;
+                var source = evt.Data.TryGetProperty("source", out var s) ? s.GetString()! : "Manual";
+                return new
+                {
+                    observationCode = code,
+                    value,
+                    unit,
+                    source = MapSource(source),
+                    recordedAt,
+                };
+            }).ToList();
+
+            foreach (var chunk in batch.Chunk(10))
+            {
+                var resp = await client.PostAsJsonAsync(
+                    $"/api/v1/encounters/{encounter.Id}/observations",
+                    new { observations = chunk }, ct);
+                resp.EnsureSuccessStatusCode();
+            }
+        }
+
+        return (patient.Id, encounter.Id);
+    }
+
+    public static async Task<SofaScore> WaitForSofaScoreAsync(
+        IServiceProvider services,
+        Guid encounterId,
+        TimeSpan timeout)
+    {
+        var deadline = DateTime.UtcNow + timeout;
+        while (DateTime.UtcNow < deadline)
+        {
+            using var scope = services.CreateScope();
+            var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();
+            var sofa = await db.SofaScores
+                .Where(s => s.EncounterId == encounterId)
+                .OrderByDescending(s => s.CalculatedAt)
+                .FirstOrDefaultAsync();
+            if (sofa is not null)
+                return sofa;
+            await Task.Delay(500);
+        }
+        throw new TimeoutException($"Timed out waiting for SOFA score on encounter {encounterId}");
+    }
+
+    public static async Task WaitForAlertTypeAsync(
+        IServiceProvider services,
+        Guid encounterId,
+        AlertType alertType,
+        TimeSpan timeout)
+    {
+        var deadline = DateTime.UtcNow + timeout;
+        while (DateTime.UtcNow < deadline)
+        {
+            using var scope = services.CreateScope();
+            var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();
+            if (await db.ClinicalAlerts.AnyAsync(a =>
+                    a.EncounterId == encounterId && a.AlertType == alertType))
+                return;
+            await Task.Delay(500);
+        }
+        throw new TimeoutException($"Timed out waiting for {alertType} on encounter {encounterId}");
+    }
+
+    public static async Task AssertNoAlertTypeAsync(
+        IServiceProvider services,
+        Guid encounterId,
+        AlertType alertType,
+        TimeSpan settleDelay)
+    {
+        await Task.Delay(settleDelay);
+        using var scope = services.CreateScope();
+        var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();
+        var found = await db.ClinicalAlerts.AnyAsync(a =>
+            a.EncounterId == encounterId && a.AlertType == alertType);
+        if (found)
+            throw new InvalidOperationException($"Unexpected {alertType} alert on encounter {encounterId}");
+    }
+
+    private static string MapSource(string source) => source.ToLowerInvariant() switch
+    {
+        "device" or "monitor" => "Device",
+        "lab" => "Lab",
+        _ => "Manual",
+    };
+
+    private record ApiEnvelope<T>(T Data);
+    private record PatientDto(Guid Id);
+    private record EncounterDto(Guid Id);
+}
@@ -53,7 +53,7 @@ public class SepsisRefactorTests : IAsyncLifetime
        await qsofa.ProcessObservationAsync(_encounterId, _patientId, "RESP_RATE", 22m);
        await qsofa.ProcessObservationAsync(_encounterId, _patientId, "WBC_K_UL", 15m);

-        (await db.ClinicalAlerts.CountAsync(a => a.AlertType == AlertType.SepsisWarning))
+        (await db.ClinicalAlerts.CountAsync(a => a.AlertType == AlertTypeExtensions.FromDbString("SEPSIS_WARNING")))
            .Should().Be(0);
    }

@@ -124,20 +124,20 @@ public class SepsisRefactorTests : IAsyncLifetime
        db.ClinicalAlerts.Add(new ClinicalAlert
        {
            Id = Guid.NewGuid(), EncounterId = _encounterId, PatientId = _patientId,
-            AlertType = AlertType.SepsisWarning, Severity = AlertSeverity.Critical,
+            AlertType = AlertTypeExtensions.FromDbString("SEPSIS_WARNING"), Severity = AlertSeverity.Critical,
            Details = "Legacy SIRS alert", Status = AlertStatus.Resolved,
            TriggeredAt = DateTimeOffset.UtcNow.AddDays(-1)
        });
        await db.SaveChangesAsync();

        var page = await alertService.ListByEncounterAsync(_encounterId, null, 1, 10);
-        page.Items.Should().ContainSingle(a => a.AlertType == AlertType.SepsisWarning);
+        page.Items.Should().ContainSingle(a => a.AlertType == AlertTypeExtensions.FromDbString("SEPSIS_WARNING"));
    }

    [Fact]
    public void CannotCreateNewSepsisWarning()
    {
-        var act = () => AlertCreationGuard.EnsureAllowed(AlertType.SepsisWarning);
+        var act = () => AlertCreationGuard.EnsureAllowed(AlertTypeExtensions.FromDbString("SEPSIS_WARNING"));
        act.Should().Throw<InvalidOperationException>()
            .WithMessage("*deprecated*");
    }
@@ -28,4 +28,9 @@
    <ProjectReference Include="..\VigilCareClinicalAPI\VigilCareClinicalAPI.csproj" />
  </ItemGroup>

+  <ItemGroup>
+    <Compile Include="..\VigilCare.Simulator\Scenarios\ScenarioFile.cs" Link="Scenarios\ScenarioFile.cs" />
+    <Compile Include="..\VigilCare.Simulator\Scenarios\ScenarioValidator.cs" Link="Scenarios\ScenarioValidator.cs" />
+  </ItemGroup>
+
 </Project>
@@ -11,13 +11,11 @@ public class GcsController : ControllerBase

    [HttpGet]
    [ProducesResponseType(typeof(ApiResponse<GcsScoreResponse>), StatusCodes.Status200OK)]
-    [ProducesResponseType(typeof(ApiResponse<object>), StatusCodes.Status404NotFound)]
    public async Task<IActionResult> Current(Guid encounterId)
    {
        var score = await _gcs.GetCurrentAsync(encounterId);
        if (score is null)
-            return NotFound(ApiResponse<object>.Fail(
-                404, "No GCS score computed for this encounter.", "NO_GCS_SCORE"));
+            return Ok(ApiResponse<GcsScoreResponse?>.Ok(null));

        return Ok(ApiResponse<GcsScoreResponse>.Ok(new GcsScoreResponse(
            score.EyeScore, score.VerbalScore, score.MotorScore,
@@ -18,12 +18,11 @@ public class News2Controller : ControllerBase
    /// </summary>
    [HttpGet("current")]
    [ProducesResponseType(typeof(ApiResponse<News2Score>), StatusCodes.Status200OK)]
-    [ProducesResponseType(typeof(ApiResponse<object>), StatusCodes.Status404NotFound)]
    public async Task<IActionResult> Current(Guid encounterId)
    {
        var score = await _news2.GetCurrentAsync(encounterId);
        if (score is null)
-            return NotFound(ApiResponse<object>.Fail(404, "No NEWS2 score computed for this encounter.", "NO_NEWS2_SCORE"));
+            return Ok(ApiResponse<News2Score?>.Ok(null));
        return Ok(ApiResponse<News2Score>.Ok(score));
    }

@@ -17,12 +17,11 @@ public class SepsisBundlesController : ControllerBase
    /// <param name="encounterId">Encounter id.</param>
    [HttpGet("api/v1/encounters/{encounterId:guid}/sepsis-bundle/current")]
    [ProducesResponseType(typeof(ApiResponse<SepsisBundle>), StatusCodes.Status200OK)]
-    [ProducesResponseType(typeof(ApiResponse<object>), StatusCodes.Status404NotFound)]
    public async Task<IActionResult> GetCurrentByEncounter(Guid encounterId)
    {
        var bundle = await _bundles.GetCurrentByEncounterAsync(encounterId);
        if (bundle is null)
-            return NotFound(ApiResponse<object>.Fail(404, "No sepsis bundle exists for this encounter.", "BUNDLE_NOT_FOUND"));
+            return Ok(ApiResponse<SepsisBundle?>.Ok(null));

        return Ok(ApiResponse<SepsisBundle>.Ok(bundle));
    }
@@ -12,13 +12,11 @@ public class SofaController : ControllerBase

    [HttpGet]
    [ProducesResponseType(typeof(ApiResponse<SofaScoreResponse>), StatusCodes.Status200OK)]
-    [ProducesResponseType(typeof(ApiResponse<object>), StatusCodes.Status404NotFound)]
    public async Task<IActionResult> Current(Guid encounterId)
    {
        var score = await _sofa.GetCurrentAsync(encounterId);
        if (score is null)
-            return NotFound(ApiResponse<object>.Fail(
-                404, "No SOFA score computed for this encounter.", "NO_SOFA_SCORE"));
+            return Ok(ApiResponse<SofaScoreResponse?>.Ok(null));

        return Ok(ApiResponse<SofaScoreResponse>.Ok(MapResponse(score)));
    }
@@ -48,150 +48,7 @@ public static class DataSeeder
        };
        db.Encounters.AddRange(encounter1, encounter2);

-        // Four alert thresholds
-        var thresholds = new List<AlertThreshold>
-        {
-            new() {
-                Id = Guid.NewGuid(), ObservationCode = "HEART_RATE", DisplayName = "Heart Rate",
-                Unit = "bpm", CriticalLow = 30, WarningLow = 50, WarningHigh = 100, CriticalHigh = 150,
-                CreatedAt = DateTimeOffset.UtcNow
-            },
-            new() {
-                Id = Guid.NewGuid(), ObservationCode = "TEMP_C", DisplayName = "Body Temperature",
-                Unit = "°C", CriticalLow = 35.0m, WarningLow = 36.0m, WarningHigh = 38.3m, CriticalHigh = 40.0m,
-                CreatedAt = DateTimeOffset.UtcNow
-            },
-            new() {
-                Id = Guid.NewGuid(), ObservationCode = "POTASSIUM_MEQ_L", DisplayName = "Serum Potassium",
-                Unit = "mEq/L", CriticalLow = 2.5m, WarningLow = 3.5m, WarningHigh = 5.0m, CriticalHigh = 6.5m,
-                CreatedAt = DateTimeOffset.UtcNow
-            },
-            new() {
-                Id = Guid.NewGuid(), ObservationCode = "SPO2", DisplayName = "Oxygen Saturation",
-                Unit = "%", CriticalLow = 88, WarningLow = 92, WarningHigh = null, CriticalHigh = null,
-                CreatedAt = DateTimeOffset.UtcNow
-            },
-            new AlertThreshold
-            {
-                Id = Guid.NewGuid(), ObservationCode = "RESP_RATE",
-                DisplayName = "Respiratory Rate", Unit = "breaths/min",
-                CriticalLow = null, WarningLow = 12m, WarningHigh = 20m, CriticalHigh = 30m,
-                CreatedAt = DateTimeOffset.UtcNow
-            },
-            new AlertThreshold
-            {
-                Id = Guid.NewGuid(), ObservationCode = "WBC_K_UL",
-                DisplayName = "White Blood Cell Count", Unit = "k/µL",
-                CriticalLow = 2.0m, WarningLow = 4.0m, WarningHigh = 12.0m, CriticalHigh = 20.0m,
-                CreatedAt = DateTimeOffset.UtcNow
-            },
-            new AlertThreshold
-            {
-                Id = Guid.NewGuid(), ObservationCode = "SYSTOLIC_BP",
-                DisplayName = "Systolic Blood Pressure", Unit = "mmHg",
-                CriticalLow = 70m, WarningLow = 90m, WarningHigh = 160m, CriticalHigh = 180m,
-                CreatedAt = DateTimeOffset.UtcNow
-            },
-            new AlertThreshold
-            {
-                Id = Guid.NewGuid(), ObservationCode = "DIASTOLIC_BP",
-                DisplayName = "Diastolic Blood Pressure", Unit = "mmHg",
-                CriticalLow = 40m, WarningLow = 60m, WarningHigh = 90m, CriticalHigh = 110m,
-                CreatedAt = DateTimeOffset.UtcNow
-            },
-            new AlertThreshold
-            {
-                Id = Guid.NewGuid(), ObservationCode = "LACTATE_MMOL_L",
-                DisplayName = "Serum Lactate", Unit = "mmol/L",
-                CriticalLow = null, WarningLow = null, WarningHigh = 2.0m, CriticalHigh = 4.0m,
-                CreatedAt = DateTimeOffset.UtcNow
-            },
-            new AlertThreshold
-            {
-                Id = Guid.NewGuid(), ObservationCode = "AVPU",
-                DisplayName = "AVPU Consciousness Level", Unit = "score",
-                CriticalLow = null, WarningLow = null, WarningHigh = null, CriticalHigh = 2m,
-                CreatedAt = DateTimeOffset.UtcNow
-            },
-            new AlertThreshold
-            {
-                Id = Guid.NewGuid(), ObservationCode = "SUPPLEMENTAL_O2",
-                DisplayName = "Supplemental Oxygen", Unit = "flag",
-                CriticalLow = null, WarningLow = null, WarningHigh = null, CriticalHigh = null,
-                CreatedAt = DateTimeOffset.UtcNow
-            },
-            new AlertThreshold
-            {
-                Id = Guid.NewGuid(), ObservationCode = "GLUCOSE_MG_DL",
-                DisplayName = "Blood Glucose", Unit = "mg/dL",
-                CriticalLow = 40m, WarningLow = 70m, WarningHigh = 180m, CriticalHigh = 400m,
-                CreatedAt = DateTimeOffset.UtcNow
-            },
-            // GCS components — registered for ingestion; thresholds are null (alerting is on computed total in GcsDetector)
-            new AlertThreshold
-            {
-                Id = Guid.NewGuid(), ObservationCode = "GCS_EYE",
-                DisplayName = "GCS Eye Response", Unit = "score",
-                CriticalLow = null, WarningLow = null, WarningHigh = null, CriticalHigh = null,
-                CreatedAt = DateTimeOffset.UtcNow
-            },
-            new AlertThreshold
-            {
-                Id = Guid.NewGuid(), ObservationCode = "GCS_VERBAL",
-                DisplayName = "GCS Verbal Response", Unit = "score",
-                CriticalLow = null, WarningLow = null, WarningHigh = null, CriticalHigh = null,
-                CreatedAt = DateTimeOffset.UtcNow
-            },
-            new AlertThreshold
-            {
-                Id = Guid.NewGuid(), ObservationCode = "GCS_MOTOR",
-                DisplayName = "GCS Motor Response", Unit = "score",
-                CriticalLow = null, WarningLow = null, WarningHigh = null, CriticalHigh = null,
-                CreatedAt = DateTimeOffset.UtcNow
-            },
-            new AlertThreshold
-            {
-                Id = Guid.NewGuid(), ObservationCode = "PAO2_MMHG",
-                DisplayName = "Partial Pressure O2 (Arterial)", Unit = "mmHg",
-                CriticalLow = 60m, WarningLow = 80m, WarningHigh = null, CriticalHigh = null,
-                CreatedAt = DateTimeOffset.UtcNow
-            },
-            new AlertThreshold
-            {
-                Id = Guid.NewGuid(), ObservationCode = "FIO2_PCT",
-                DisplayName = "Fraction of Inspired O2", Unit = "%",
-                CriticalLow = null, WarningLow = null, WarningHigh = null, CriticalHigh = null,
-                CreatedAt = DateTimeOffset.UtcNow
-            },
-            new AlertThreshold
-            {
-                Id = Guid.NewGuid(), ObservationCode = "PLATELET_K_UL",
-                DisplayName = "Platelet Count", Unit = "k/µL",
-                CriticalLow = 20m, WarningLow = 50m, WarningHigh = null, CriticalHigh = null,
-                CreatedAt = DateTimeOffset.UtcNow
-            },
-            new AlertThreshold
-            {
-                Id = Guid.NewGuid(), ObservationCode = "BILIRUBIN_MG_DL",
-                DisplayName = "Total Bilirubin", Unit = "mg/dL",
-                CriticalLow = null, WarningLow = null, WarningHigh = 2.0m, CriticalHigh = 6.0m,
-                CreatedAt = DateTimeOffset.UtcNow
-            },
-            new AlertThreshold
-            {
-                Id = Guid.NewGuid(), ObservationCode = "CREATININE_MG_DL",
-                DisplayName = "Serum Creatinine", Unit = "mg/dL",
-                CriticalLow = null, WarningLow = null, WarningHigh = 2.0m, CriticalHigh = 3.5m,
-                CreatedAt = DateTimeOffset.UtcNow
-            },
-            new AlertThreshold
-            {
-                Id = Guid.NewGuid(), ObservationCode = "URINE_OUTPUT_ML_H",
-                DisplayName = "Urine Output", Unit = "mL/h",
-                CriticalLow = null, WarningLow = null, WarningHigh = null, CriticalHigh = null,
-                CreatedAt = DateTimeOffset.UtcNow
-            },
-        };
+        var thresholds = BuildDefaultThresholds();
        db.AlertThresholds.AddRange(thresholds);

        // Observations spanning normal, warning, and critical ranges for encounter1
@@ -235,8 +92,163 @@ public static class DataSeeder
        db.Observations.AddRange(observations);

        await db.SaveChangesAsync();
+        await CacheThresholdsAsync(redis, thresholds);
+    }

-        // Populate Redis cache with the seeded thresholds
+    public static async Task SeedThresholdsOnlyAsync(AppDbContext db, IConnectionMultiplexer redis)
+    {
+        var thresholds = BuildDefaultThresholds();
+        db.AlertThresholds.AddRange(thresholds);
+        await db.SaveChangesAsync();
+        await CacheThresholdsAsync(redis, thresholds);
+    }
+
+    public static List<AlertThreshold> BuildDefaultThresholds() => new()
+    {
+        new() {
+            Id = Guid.NewGuid(), ObservationCode = "HEART_RATE", DisplayName = "Heart Rate",
+            Unit = "bpm", CriticalLow = 30, WarningLow = 50, WarningHigh = 100, CriticalHigh = 150,
+            CreatedAt = DateTimeOffset.UtcNow
+        },
+        new() {
+            Id = Guid.NewGuid(), ObservationCode = "TEMP_C", DisplayName = "Body Temperature",
+            Unit = "°C", CriticalLow = 35.0m, WarningLow = 36.0m, WarningHigh = 38.3m, CriticalHigh = 40.0m,
+            CreatedAt = DateTimeOffset.UtcNow
+        },
+        new() {
+            Id = Guid.NewGuid(), ObservationCode = "POTASSIUM_MEQ_L", DisplayName = "Serum Potassium",
+            Unit = "mEq/L", CriticalLow = 2.5m, WarningLow = 3.5m, WarningHigh = 5.0m, CriticalHigh = 6.5m,
+            CreatedAt = DateTimeOffset.UtcNow
+        },
+        new() {
+            Id = Guid.NewGuid(), ObservationCode = "SPO2", DisplayName = "Oxygen Saturation",
+            Unit = "%", CriticalLow = 88, WarningLow = 92, WarningHigh = null, CriticalHigh = null,
+            CreatedAt = DateTimeOffset.UtcNow
+        },
+        new AlertThreshold
+        {
+            Id = Guid.NewGuid(), ObservationCode = "RESP_RATE",
+            DisplayName = "Respiratory Rate", Unit = "breaths/min",
+            CriticalLow = null, WarningLow = 12m, WarningHigh = 20m, CriticalHigh = 30m,
+            CreatedAt = DateTimeOffset.UtcNow
+        },
+        new AlertThreshold
+        {
+            Id = Guid.NewGuid(), ObservationCode = "WBC_K_UL",
+            DisplayName = "White Blood Cell Count", Unit = "k/µL",
+            CriticalLow = 2.0m, WarningLow = 4.0m, WarningHigh = 12.0m, CriticalHigh = 20.0m,
+            CreatedAt = DateTimeOffset.UtcNow
+        },
+        new AlertThreshold
+        {
+            Id = Guid.NewGuid(), ObservationCode = "SYSTOLIC_BP",
+            DisplayName = "Systolic Blood Pressure", Unit = "mmHg",
+            CriticalLow = 70m, WarningLow = 90m, WarningHigh = 160m, CriticalHigh = 180m,
+            CreatedAt = DateTimeOffset.UtcNow
+        },
+        new AlertThreshold
+        {
+            Id = Guid.NewGuid(), ObservationCode = "DIASTOLIC_BP",
+            DisplayName = "Diastolic Blood Pressure", Unit = "mmHg",
+            CriticalLow = 40m, WarningLow = 60m, WarningHigh = 90m, CriticalHigh = 110m,
+            CreatedAt = DateTimeOffset.UtcNow
+        },
+        new AlertThreshold
+        {
+            Id = Guid.NewGuid(), ObservationCode = "LACTATE_MMOL_L",
+            DisplayName = "Serum Lactate", Unit = "mmol/L",
+            CriticalLow = null, WarningLow = null, WarningHigh = 2.0m, CriticalHigh = 4.0m,
+            CreatedAt = DateTimeOffset.UtcNow
+        },
+        new AlertThreshold
+        {
+            Id = Guid.NewGuid(), ObservationCode = "AVPU",
+            DisplayName = "AVPU Consciousness Level", Unit = "score",
+            CriticalLow = null, WarningLow = null, WarningHigh = null, CriticalHigh = 2m,
+            CreatedAt = DateTimeOffset.UtcNow
+        },
+        new AlertThreshold
+        {
+            Id = Guid.NewGuid(), ObservationCode = "SUPPLEMENTAL_O2",
+            DisplayName = "Supplemental Oxygen", Unit = "flag",
+            CriticalLow = null, WarningLow = null, WarningHigh = null, CriticalHigh = null,
+            CreatedAt = DateTimeOffset.UtcNow
+        },
+        new AlertThreshold
+        {
+            Id = Guid.NewGuid(), ObservationCode = "GLUCOSE_MG_DL",
+            DisplayName = "Blood Glucose", Unit = "mg/dL",
+            CriticalLow = 40m, WarningLow = 70m, WarningHigh = 180m, CriticalHigh = 400m,
+            CreatedAt = DateTimeOffset.UtcNow
+        },
+        new AlertThreshold
+        {
+            Id = Guid.NewGuid(), ObservationCode = "GCS_EYE",
+            DisplayName = "GCS Eye Response", Unit = "score",
+            CriticalLow = null, WarningLow = null, WarningHigh = null, CriticalHigh = null,
+            CreatedAt = DateTimeOffset.UtcNow
+        },
+        new AlertThreshold
+        {
+            Id = Guid.NewGuid(), ObservationCode = "GCS_VERBAL",
+            DisplayName = "GCS Verbal Response", Unit = "score",
+            CriticalLow = null, WarningLow = null, WarningHigh = null, CriticalHigh = null,
+            CreatedAt = DateTimeOffset.UtcNow
+        },
+        new AlertThreshold
+        {
+            Id = Guid.NewGuid(), ObservationCode = "GCS_MOTOR",
+            DisplayName = "GCS Motor Response", Unit = "score",
+            CriticalLow = null, WarningLow = null, WarningHigh = null, CriticalHigh = null,
+            CreatedAt = DateTimeOffset.UtcNow
+        },
+        new AlertThreshold
+        {
+            Id = Guid.NewGuid(), ObservationCode = "PAO2_MMHG",
+            DisplayName = "Partial Pressure O2 (Arterial)", Unit = "mmHg",
+            CriticalLow = 60m, WarningLow = 80m, WarningHigh = null, CriticalHigh = null,
+            CreatedAt = DateTimeOffset.UtcNow
+        },
+        new AlertThreshold
+        {
+            Id = Guid.NewGuid(), ObservationCode = "FIO2_PCT",
+            DisplayName = "Fraction of Inspired O2", Unit = "%",
+            CriticalLow = null, WarningLow = null, WarningHigh = null, CriticalHigh = null,
+            CreatedAt = DateTimeOffset.UtcNow
+        },
+        new AlertThreshold
+        {
+            Id = Guid.NewGuid(), ObservationCode = "PLATELET_K_UL",
+            DisplayName = "Platelet Count", Unit = "k/µL",
+            CriticalLow = 20m, WarningLow = 50m, WarningHigh = null, CriticalHigh = null,
+            CreatedAt = DateTimeOffset.UtcNow
+        },
+        new AlertThreshold
+        {
+            Id = Guid.NewGuid(), ObservationCode = "BILIRUBIN_MG_DL",
+            DisplayName = "Total Bilirubin", Unit = "mg/dL",
+            CriticalLow = null, WarningLow = null, WarningHigh = 2.0m, CriticalHigh = 6.0m,
+            CreatedAt = DateTimeOffset.UtcNow
+        },
+        new AlertThreshold
+        {
+            Id = Guid.NewGuid(), ObservationCode = "CREATININE_MG_DL",
+            DisplayName = "Serum Creatinine", Unit = "mg/dL",
+            CriticalLow = null, WarningLow = null, WarningHigh = 2.0m, CriticalHigh = 3.5m,
+            CreatedAt = DateTimeOffset.UtcNow
+        },
+        new AlertThreshold
+        {
+            Id = Guid.NewGuid(), ObservationCode = "URINE_OUTPUT_ML_H",
+            DisplayName = "Urine Output", Unit = "mL/h",
+            CriticalLow = null, WarningLow = null, WarningHigh = null, CriticalHigh = null,
+            CreatedAt = DateTimeOffset.UtcNow
+        },
+    };
+
+    private static async Task CacheThresholdsAsync(
+        IConnectionMultiplexer redis, IEnumerable<AlertThreshold> thresholds)
+    {
        var cache = redis.GetDatabase();
        foreach (var t in thresholds)
        {
@@ -9,7 +9,8 @@ public class SofaDetector
 {
    private static readonly JsonSerializerOptions JsonOptions = new()
    {
-        PropertyNameCaseInsensitive = true
+        PropertyNameCaseInsensitive = true,
+        PropertyNamingPolicy = JsonNamingPolicy.CamelCase
    };

    private readonly IConnectionMultiplexer _redis;
@@ -0,0 +1,21 @@
+```markdown
+# Clinical Refactor — SOFA / GCS Interview Questions
+
+## Q1: Why did you replace SIRS with SOFA for sepsis detection?
+
+SIRS (Systemic Inflammatory Response Syndrome) uses four criteria — temperature, heart rate, respiratory rate, white blood cell count — to screen for sepsis. The problem is non-specificity: a patient who just exercised, is anxious, or has a mild viral infection can meet ≥ 2 criteria. The Sepsis-3 consensus (2016) replaced SIRS with SOFA (Sequential Organ Failure Assessment) because SOFA measures actual organ dysfunction across six systems. A delta SOFA ≥ 2 from baseline in the presence of suspected infection is both more specific and more clinically actionable than SIRS. We kept qSOFA as a bedside screening tool that recommends ordering SOFA labs, matching the Sepsis-3 two-tier approach.
+
+## Q2: How does your system handle the fact that SOFA requires lab values that aren't continuously available?
+
+Three strategies: **carry-forward with staleness** — the most recent lab value is cached in Redis with a configurable TTL (default 24 hours) and classified as CURRENT (< 12h), STALE (12–24h), or EXPIRED (> 24h). Stale values are still used for scoring but flagged in `sofa_scores.staleness_flags` JSON so clinicians know the score is based on older data. Second, **SpO₂/FiO₂ fallback** — when arterial blood gas isn't available (common on general wards), we use the SpO₂/FiO₂ ratio as a proxy for the respiratory component, per Rice et al. (2007). Third, **partial scoring** — SOFA baseline is only established when ≥ 4 of 6 organ systems have data, preventing false low baselines that would inflate the delta.
+
+## Q3: Why did you keep qSOFA after removing SIRS, and how does the screening workflow differ from the old SIRS alert?
+
+qSOFA is a validated bedside screening tool — three simple criteria (respiratory rate, blood pressure, mental status) that any nurse can assess without labs. The key change is clinical positioning: under SIRS, meeting ≥ 2 criteria immediately declared sepsis and triggered the treatment bundle. Under the new workflow, qSOFA ≥ 2 creates a WARNING-level screening alert (`QSOFA_SCREEN`) that recommends ordering SOFA labs (PaO₂/FiO₂, platelets, bilirubin, creatinine). Only when those labs confirm organ dysfunction — SOFA delta ≥ 2 — does the system declare sepsis (`SOFA_SEPSIS`) and trigger the bundle. This prevents false-positive bundle activations that occurred with SIRS.
+
+## Q4: How did you handle the GCS → SOFA → NEWS2 → qSOFA dependency chain?
+
+GCS feeds into three downstream systems: SOFA CNS scoring (GCS → 0–4 organ score), NEWS2 consciousness (GCS 15 = score 0, GCS < 15 = score 3), and qSOFA altered mentation (GCS < 15 = criterion met). Architecturally, the GCS Kafka consumer computes the total and caches it in Redis. Downstream consumers (SOFA, NEWS2, qSOFA) read GCS from Redis when triggered. The resolution order is **GCS-first with AVPU-fallback** — if GCS components exist, they take priority; if only AVPU is available (legacy data), the old mapping still works. This avoided a breaking migration while making GCS the preferred consciousness assessment going forward.
+```
+
+Also update `docs/clinical-scoring-refactor-summary.md` — add a "Phase 29 scenarios" section listing the three new scenario IDs and what each validates.
@@ -0,0 +1,40 @@
+#!/usr/bin/env bash
+set -euo pipefail
+
+SCRIPT_DIR="$(cd "$(dirname "${BASH_SOURCE[0]}")" && pwd)"
+ROOT_DIR="$(cd "${SCRIPT_DIR}/.." && pwd)"
+
+echo "=== Phase 28 verification ==="
+
+echo "1. Dashboard unit tests"
+cd "${ROOT_DIR}/vigilcare-dashboard"
+npm test
+
+echo "2. Manual UI checks (requires running stack + dashboard dev server)"
+BASE_URL="${BASE_URL:-http://localhost:5270}"
+DASH_URL="${DASH_URL:-http://localhost:5173}"
+ENCOUNTER_ID="${ENCOUNTER_ID:?Set ENCOUNTER_ID to an active encounter UUID}"
+
+post_gcs() {
+  local eye="$1" verbal="$2" motor="$3"
+  curl -sf -X POST "${BASE_URL}/api/v1/encounters/${ENCOUNTER_ID}/observations" \
+    -H "Content-Type: application/json" \
+    -d "{\"observations\":[
+      {\"observationCode\":\"GCS_EYE\",\"value\":${eye},\"unit\":\"score\",\"source\":\"Manual\",\"recordedAt\":\"$(date -u +%Y-%m-%dT%H:%M:%SZ)\"},
+      {\"observationCode\":\"GCS_VERBAL\",\"value\":${verbal},\"unit\":\"score\",\"source\":\"Manual\",\"recordedAt\":\"$(date -u +%Y-%m-%dT%H:%M:%SZ)\"},
+      {\"observationCode\":\"GCS_MOTOR\",\"value\":${motor},\"unit\":\"score\",\"source\":\"Manual\",\"recordedAt\":\"$(date -u +%Y-%m-%dT%H:%M:%SZ)\"}
+    ]}"
+}
+
+post_gcs 3 4 5
+curl -sf "${BASE_URL}/api/v1/encounters/${ENCOUNTER_ID}/gcs" | jq -e '.data.totalScore == 12'
+curl -sf "${BASE_URL}/api/v1/encounters/${ENCOUNTER_ID}/sofa" || echo "(SOFA 404 OK if labs not yet ingested)"
+
+echo "Open ${DASH_URL}/encounters/${ENCOUNTER_ID} and verify:"
+echo "  - ScoresPanel: NEWS2, GCS, SOFA, qSOFA Screen sections"
+echo "  - GCS form: E=3 V=4 M=5 → total 12 Moderate"
+echo "  - SofaScorePanel: 6-organ grid or Labs pending"
+echo "  - SepsisBundlePanel: SOFA trigger label or qSOFA screen message"
+echo "  - Alert Center: new alert type labels; no SIRS except legacy"
+
+echo "Phase 28 verification complete."
@@ -0,0 +1,35 @@
+#!/usr/bin/env bash
+set -euo pipefail
+
+SCRIPT_DIR="$(cd "$(dirname "${BASH_SOURCE[0]}")" && pwd)"
+ROOT_DIR="$(cd "${SCRIPT_DIR}/.." && pwd)"
+SIM_DIR="${ROOT_DIR}/VigilCare.Simulator"
+BASE_URL="${BASE_URL:-http://localhost:5270}"
+
+echo "=== Phase 29 — Clinical Refactor Validation ==="
+
+echo "1. Validate all scenario JSON files"
+for scenario in "${SIM_DIR}"/Scenarios/List/*.json; do
+  dotnet run --project "${SIM_DIR}" -- validate "${scenario}"
+done
+
+echo "2. Integration tests"
+dotnet test "${ROOT_DIR}/VigilCareClinicalAPI.Tests" \
+  --filter "FullyQualifiedName~ClinicalRefactorEndToEnd" \
+  --no-restore
+
+echo "3. Replay new scenarios (requires running API at ${BASE_URL})"
+cd "${SIM_DIR}"
+dotnet run -- replay Scenarios/List/sepsis-sofa-progression-01.json --speed 0 --poll --base-url "${BASE_URL}"
+dotnet run -- replay Scenarios/List/neurological-decline-gcs-01.json --speed 0 --poll --base-url "${BASE_URL}"
+dotnet run -- replay Scenarios/List/sofa-partial-spo2-fallback-01.json --speed 0 --poll --base-url "${BASE_URL}"
+
+echo "4. Replay-all backward compat"
+dotnet run -- replay-all Scenarios/List --speed 0 --base-url "${BASE_URL}"
+
+echo "5. Dashboard tests (Phase 28 UI)"
+cd "${ROOT_DIR}/vigilcare-dashboard"
+npm test
+
+echo "Phase 29 verification complete."
+echo "Manual: open patient detail after sepsis-sofa-progression replay — verify GCS/SOFA panels and SOFA-triggered bundle."
@@ -13,8 +13,23 @@ async function request(path, options = {}) {
  return envelope.data
 }

+/** Returns null when the resource does not exist yet (HTTP 404 or empty optional payload). */
+async function requestOptional(path) {
+  const res = await fetch(`${BASE_URL}${path}`, {
+    headers: { 'Content-Type': 'application/json' },
+  })
+  const envelope = await res.json()
+  if (res.status === 404) return null
+  if (!res.ok || !envelope.success) {
+    const msg = envelope.error?.message ?? `API ${res.status}: ${path}`
+    throw new Error(msg)
+  }
+  return envelope.data ?? null
+}
+
 export const api = {
  get: (path) => request(path),
+  getOptional: (path) => requestOptional(path),
  post: (path, body) => request(path, {
    method: 'POST',
    body: body !== undefined ? JSON.stringify(body) : undefined,
@@ -1,7 +1,7 @@
 import { api } from './client'

 export function fetchCurrentNews2(encounterId) {
-  return api.get(`/api/v1/encounters/${encounterId}/news2/current`)
+  return api.getOptional(`/api/v1/encounters/${encounterId}/news2/current`)
 }

 export function fetchCurrentQsofa(encounterId) {
@@ -9,15 +9,15 @@ export function fetchCurrentQsofa(encounterId) {
 }

 export function fetchCurrentGcs(encounterId) {
-  return api.get(`/api/v1/encounters/${encounterId}/gcs`)
+  return api.getOptional(`/api/v1/encounters/${encounterId}/gcs`)
 }

 export function fetchCurrentSofa(encounterId) {
-  return api.get(`/api/v1/encounters/${encounterId}/sofa`)
+  return api.getOptional(`/api/v1/encounters/${encounterId}/sofa`)
 }

 export function fetchSepsisBundle(encounterId) {
-  return api.get(`/api/v1/encounters/${encounterId}/sepsis-bundle/current`)
+  return api.getOptional(`/api/v1/encounters/${encounterId}/sepsis-bundle/current`)
 }

 export function fetchOrders(encounterId) {
@@ -68,10 +68,10 @@ export const useScoringStore = defineStore('scoring', () => {
    const id = encounterId.value
    try {
      const [g, s, n, q] = await Promise.all([
-        clinicalApi.fetchCurrentGcs(id).catch(() => null),
-        clinicalApi.fetchCurrentSofa(id).catch(() => null),
-        clinicalApi.fetchCurrentNews2(id).catch(() => null),
-        clinicalApi.fetchCurrentQsofa(id).catch(() => null),
+        clinicalApi.fetchCurrentGcs(id),
+        clinicalApi.fetchCurrentSofa(id),
+        clinicalApi.fetchCurrentNews2(id),
+        clinicalApi.fetchCurrentQsofa(id),
      ])
      gcs.value = g
      sofa.value = s
@@ -94,6 +94,7 @@ export const useScoringStore = defineStore('scoring', () => {
  }

  function startPolling(id) {
+    if (encounterId.value === id && timer) return
    stopPolling()
    encounterId.value = id
    refresh()
@@ -93,7 +93,7 @@ async function loadAll() {
      encountersApi.fetchObservations(id),
      clinicalApi.fetchNews2History(id).catch(() => []),
      clinicalApi.fetchMedications(id).catch(() => []),
-      clinicalApi.fetchSepsisBundle(id).catch(() => null),
+      clinicalApi.fetchSepsisBundle(id),
      clinicalApi.fetchOrders(id).catch(() => ({ items: [] })),
    ])
    await alertStore.loadAlerts(id)
				`@@ -0,0 +1 @@`
				`public record QsofaResponse(int ActiveCriteria);`