feature: qSOFA Scoring & Sepsis Bundle Compliance
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voltsrage
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using FluentAssertions;
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using Microsoft.EntityFrameworkCore;
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using Microsoft.Extensions.DependencyInjection;
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using StackExchange.Redis;
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[Collection("Integration")]
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public class QsofaDetectorTests : IAsyncLifetime
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{
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private readonly ApiFixture _fixture;
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private Guid _encounterId;
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private Guid _patientId;
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public QsofaDetectorTests(ApiFixture fixture) => _fixture = fixture;
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public async Task InitializeAsync()
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{
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using var scope = _fixture.Services.CreateScope();
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var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();
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await DbResetHelper.ResetAsync(db);
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var patient = new Patient
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{
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Id = Guid.NewGuid(), Mrn = "MRN-QSOFA-001", FirstName = "qSOFA", LastName = "Test",
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DateOfBirth = new DateOnly(1960, 1, 1), Gender = "M",
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CreatedAt = DateTimeOffset.UtcNow
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};
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var encounter = new Encounter
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{
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Id = Guid.NewGuid(), PatientId = patient.Id, EncounterType = EncounterType.Inpatient,
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Status = EncounterStatus.Active, Department = Department.Icu,
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AttendingPhysician = "Dr. qSOFA", AdmittedAt = DateTimeOffset.UtcNow,
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CreatedAt = DateTimeOffset.UtcNow
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};
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db.Patients.Add(patient);
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db.Encounters.Add(encounter);
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await db.SaveChangesAsync();
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_patientId = patient.Id;
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_encounterId = encounter.Id;
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var redis = scope.ServiceProvider.GetRequiredService<IConnectionMultiplexer>();
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var cache = redis.GetDatabase();
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foreach (var key in QsofaCalculator.AllCriterionKeys(_encounterId))
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await cache.KeyDeleteAsync(key);
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}
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public Task DisposeAsync() => Task.CompletedTask;
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[Fact]
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public async Task OneCriterionMet_NoAlert()
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{
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using var scope = _fixture.Services.CreateScope();
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var detector = scope.ServiceProvider.GetRequiredService<QsofaDetector>();
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var result = await detector.ProcessObservationAsync(
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_encounterId, _patientId, "RESP_RATE", 24m);
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result.Outcome.Should().Be(QsofaOutcome.InsufficientCriteria);
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result.ActiveCriteria.Should().Be(1);
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var redis = scope.ServiceProvider.GetRequiredService<IConnectionMultiplexer>();
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var ttl = await redis.GetDatabase()
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.KeyTimeToLiveAsync(QsofaCalculator.CriterionKey(_encounterId, "RESP_RATE"));
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ttl.Should().NotBeNull().And.BeGreaterThan(TimeSpan.Zero);
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}
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[Fact]
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public async Task TwoCriteriaMet_CreatesAlert()
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{
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using var scope = _fixture.Services.CreateScope();
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var detector = scope.ServiceProvider.GetRequiredService<QsofaDetector>();
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var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();
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var r1 = await detector.ProcessObservationAsync(
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_encounterId, _patientId, "RESP_RATE", 24m);
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r1.Outcome.Should().Be(QsofaOutcome.InsufficientCriteria);
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var r2 = await detector.ProcessObservationAsync(
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_encounterId, _patientId, "SYSTOLIC_BP", 95m);
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r2.Outcome.Should().Be(QsofaOutcome.AlertCreated);
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var alert = await db.ClinicalAlerts.SingleAsync();
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alert.AlertType.Should().Be(AlertType.QsofaWarning);
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alert.Severity.Should().Be(AlertSeverity.Critical);
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alert.Status.Should().Be(AlertStatus.Open);
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alert.EncounterId.Should().Be(_encounterId);
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alert.PatientId.Should().Be(_patientId);
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alert.Details.Should().Contain("qSOFA score 2/3");
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var outbox = await db.OutboxEvents.SingleAsync();
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outbox.Topic.Should().Be("alert.generated");
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outbox.PartitionKey.Should().Be(_encounterId.ToString());
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}
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[Fact]
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public async Task CriterionNormalizes_KeyDeleted()
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{
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using var scope = _fixture.Services.CreateScope();
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var detector = scope.ServiceProvider.GetRequiredService<QsofaDetector>();
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var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();
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var redis = scope.ServiceProvider.GetRequiredService<IConnectionMultiplexer>();
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var cache = redis.GetDatabase();
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await detector.ProcessObservationAsync(_encounterId, _patientId, "RESP_RATE", 24m);
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await detector.ProcessObservationAsync(_encounterId, _patientId, "SYSTOLIC_BP", 95m);
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var result = await detector.ProcessObservationAsync(
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_encounterId, _patientId, "RESP_RATE", 18m);
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var respKeyExists = await cache.KeyExistsAsync(
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QsofaCalculator.CriterionKey(_encounterId, "RESP_RATE"));
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respKeyExists.Should().BeFalse("a normalized respiratory rate must clear the criterion key");
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var sbpKeyExists = await cache.KeyExistsAsync(
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QsofaCalculator.CriterionKey(_encounterId, "SYSTOLIC_BP"));
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sbpKeyExists.Should().BeTrue("the other active criterion must remain in Redis");
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result.Outcome.Should().Be(QsofaOutcome.InsufficientCriteria);
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result.ActiveCriteria.Should().Be(1);
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var alert = await db.ClinicalAlerts.SingleAsync();
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alert.Status.Should().Be(AlertStatus.Open,
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"the existing alert is not auto-resolved when criteria drop below 2");
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}
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[Fact]
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public async Task DuplicateAlert_Idempotent()
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{
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using var scope = _fixture.Services.CreateScope();
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var detector = scope.ServiceProvider.GetRequiredService<QsofaDetector>();
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var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();
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await detector.ProcessObservationAsync(_encounterId, _patientId, "RESP_RATE", 24m);
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await detector.ProcessObservationAsync(_encounterId, _patientId, "SYSTOLIC_BP", 95m);
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var r3 = await detector.ProcessObservationAsync(
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_encounterId, _patientId, "SYSTOLIC_BP", 95m);
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r3.Outcome.Should().Be(QsofaOutcome.AlertAlreadyOpen);
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var alertCount = await db.ClinicalAlerts.CountAsync();
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alertCount.Should().Be(1, "WHERE NOT EXISTS prevents duplicate QSOFA_WARNING while one is open");
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var outboxCount = await db.OutboxEvents.CountAsync();
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outboxCount.Should().Be(1, "outbox event must be written exactly once");
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}
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[Fact]
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public async Task NonQsofaCode_Ignored()
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{
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using var scope = _fixture.Services.CreateScope();
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var detector = scope.ServiceProvider.GetRequiredService<QsofaDetector>();
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var redis = scope.ServiceProvider.GetRequiredService<IConnectionMultiplexer>();
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var result = await detector.ProcessObservationAsync(
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_encounterId, _patientId, "HEART_RATE", 95m);
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result.Outcome.Should().Be(QsofaOutcome.NotQsofaCode);
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foreach (var key in QsofaCalculator.AllCriterionKeys(_encounterId))
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{
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var exists = await redis.GetDatabase().KeyExistsAsync(key);
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exists.Should().BeFalse("non-qSOFA codes must not create Redis state");
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}
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}
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}
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