vigilcare-clinical/VigilCareClinicalAPI.Tests/SepsisBundleTests.cs

using FluentAssertions;
using Microsoft.EntityFrameworkCore;
using Microsoft.Extensions.DependencyInjection;
using Microsoft.Extensions.Logging;
using StackExchange.Redis;

[Collection("Integration")]
public class SepsisBundleTests : IAsyncLifetime
{
    private readonly ApiFixture _fixture;
    private Guid _encounterId;
    private Guid _patientId;

    public SepsisBundleTests(ApiFixture fixture) => _fixture = fixture;

    public async Task InitializeAsync()
    {
        using var scope = _fixture.Services.CreateScope();
        var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();
        await DbResetHelper.ResetAsync(db);

        var patient = new Patient
        {
            Id = Guid.NewGuid(), Mrn = "MRN-BUNDLE-001", FirstName = "Bundle", LastName = "Test",
            DateOfBirth = new DateOnly(1965, 3, 15), Gender = "F",
            CreatedAt = DateTimeOffset.UtcNow
        };
        var encounter = new Encounter
        {
            Id = Guid.NewGuid(), PatientId = patient.Id, EncounterType = EncounterType.Inpatient,
            Status = EncounterStatus.Active, Department = Department.Icu,
            AttendingPhysician = "Dr. Bundle", AdmittedAt = DateTimeOffset.UtcNow,
            CreatedAt = DateTimeOffset.UtcNow
        };
        db.Patients.Add(patient);
        db.Encounters.Add(encounter);
        await db.SaveChangesAsync();

        _patientId = patient.Id;
        _encounterId = encounter.Id;

        var redis = scope.ServiceProvider.GetRequiredService<IConnectionMultiplexer>();
        var cache = redis.GetDatabase();
        foreach (var key in QsofaCalculator.AllCriterionKeys(_encounterId))
            await cache.KeyDeleteAsync(key);
    }

    public Task DisposeAsync() => Task.CompletedTask;

    private async Task CreateSofaSepsisBundleAsync(IServiceScope scope)
    {
        var handler = scope.ServiceProvider.GetRequiredService<SepsisAlertHandler>();
        var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();

        var alertId = Guid.NewGuid();
        db.ClinicalAlerts.Add(new ClinicalAlert
        {
            Id = alertId,
            EncounterId = _encounterId,
            PatientId = _patientId,
            AlertType = AlertType.SofaSepsis,
            Severity = AlertSeverity.Critical,
            Details = "SOFA delta +2",
            Status = AlertStatus.Open,
            TriggeredAt = DateTimeOffset.UtcNow
        });
        await db.SaveChangesAsync();

        await handler.OnSepsisAlertCreatedAsync(
            _encounterId, alertId, AlertType.SofaSepsis, CancellationToken.None);
    }

    [Fact]
    public async Task SofaSepsisAlert_CreatesBundleWithFourOrders()
    {
        using var scope = _fixture.Services.CreateScope();
        var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();

        await CreateSofaSepsisBundleAsync(scope);

        var bundle = await db.SepsisBundles
            .Include(b => b.Elements)
            .SingleAsync(b => b.EncounterId == _encounterId);

        bundle.ComplianceStatus.Should().Be(SepsisBundleComplianceStatus.InProgress);
        bundle.TriggeringAlertType.Should().Be("SOFA_SEPSIS");
        bundle.DeadlineAt.Should().BeCloseTo(bundle.RecognizedAt.AddHours(1), TimeSpan.FromSeconds(5));
        bundle.Elements.Should().HaveCount(4);

        var orders = await db.Orders
            .Where(o => o.EncounterId == _encounterId)
            .ToListAsync();
        orders.Should().HaveCount(4);
        orders.Should().AllSatisfy(o =>
        {
            o.Status.Should().Be(OrderStatus.Pending);
            o.Description.Should().StartWith("SEP-1:");
            o.OrderedBy.Should().Be("sepsis-bundle-engine");
        });

        var bundleOutbox = await db.OutboxEvents
            .Where(e => e.Topic == "sepsis.bundle.created")
            .SingleAsync();
        bundleOutbox.PartitionKey.Should().Be(_encounterId.ToString());
    }

    [Fact]
    public async Task QsofaScreen_DoesNotTriggerBundle()
    {
        using var scope = _fixture.Services.CreateScope();
        var detector = scope.ServiceProvider.GetRequiredService<QsofaDetector>();
        var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();

        await detector.ProcessObservationAsync(_encounterId, _patientId, "RESP_RATE", 24m);
        await detector.ProcessObservationAsync(_encounterId, _patientId, "SYSTOLIC_BP", 95m);

        (await db.SepsisBundles.CountAsync()).Should().Be(0);
    }

    [Fact]
    public async Task SecondAlert_IdempotentBundle()
    {
        using var scope = _fixture.Services.CreateScope();
        var handler = scope.ServiceProvider.GetRequiredService<SepsisAlertHandler>();
        var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();

        await CreateSofaSepsisBundleAsync(scope);

        var bundleCountAfterFirst = await db.SepsisBundles.CountAsync(b => b.EncounterId == _encounterId);
        bundleCountAfterFirst.Should().Be(1);

        var secondAlertId = Guid.NewGuid();
        db.ClinicalAlerts.Add(new ClinicalAlert
        {
            Id = secondAlertId,
            EncounterId = _encounterId,
            PatientId = _patientId,
            AlertType = AlertType.SofaSepsis,
            Severity = AlertSeverity.Critical,
            Details = "SOFA delta +3",
            Status = AlertStatus.Open,
            TriggeredAt = DateTimeOffset.UtcNow
        });
        await db.SaveChangesAsync();
        await handler.OnSepsisAlertCreatedAsync(
            _encounterId, secondAlertId, AlertType.SofaSepsis, CancellationToken.None);

        var bundleCount = await db.SepsisBundles.CountAsync(b => b.EncounterId == _encounterId);
        bundleCount.Should().Be(1, "a second bundle must not be created while one is IN_PROGRESS");

        var orderCount = await db.Orders.CountAsync(o => o.EncounterId == _encounterId);
        orderCount.Should().Be(4, "no additional orders should be created for the duplicate bundle attempt");
    }

    [Fact]
    public async Task OrderResulted_CompletesElement()
    {
        using var scope = _fixture.Services.CreateScope();
        var bundleService = scope.ServiceProvider.GetRequiredService<ISepsisBundleService>();
        var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();

        await CreateSofaSepsisBundleAsync(scope);

        var lactateElement = await db.SepsisBundleElements
            .Include(e => e.Order)
            .SingleAsync(e => e.ElementType == SepsisBundleElementType.SerumLactate);

        await bundleService.OnOrderResultedAsync(lactateElement.OrderId!.Value);

        var updated = await db.SepsisBundleElements
            .AsNoTracking()
            .SingleAsync(e => e.Id == lactateElement.Id);

        updated.Status.Should().Be(SepsisBundleElementStatus.Completed);
        updated.CompletedAt.Should().NotBeNull();

        var bundle = await db.SepsisBundles.AsNoTracking().SingleAsync();
        bundle.ComplianceStatus.Should().Be(SepsisBundleComplianceStatus.InProgress,
            "bundle should remain in progress until all 4 elements are completed");
    }

    [Fact]
    public async Task AllElementsResulted_BundleCompliant()
    {
        using var scope = _fixture.Services.CreateScope();
        var bundleService = scope.ServiceProvider.GetRequiredService<ISepsisBundleService>();
        var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();

        await CreateSofaSepsisBundleAsync(scope);

        var elements = await db.SepsisBundleElements.ToListAsync();
        foreach (var element in elements)
            await bundleService.OnOrderResultedAsync(element.OrderId!.Value);

        var bundle = await db.SepsisBundles.AsNoTracking().SingleAsync();
        bundle.ComplianceStatus.Should().Be(SepsisBundleComplianceStatus.Compliant);
        bundle.CompletedAt.Should().NotBeNull();
        bundle.CompletedAt.Should().BeBefore(bundle.DeadlineAt,
            "all elements completed within the 1-hour window");

        var outboxEvents = await db.OutboxEvents
            .Where(e => e.Topic == "sepsis.bundle.updated")
            .ToListAsync();
        outboxEvents.Should().HaveCount(4, "one outbox event per element completion");
    }

    [Fact]
    public async Task DeadlinePassed_CompletionMarksNonCompliant()
    {
        using var scope = _fixture.Services.CreateScope();
        var bundleService = scope.ServiceProvider.GetRequiredService<ISepsisBundleService>();
        var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();

        await CreateSofaSepsisBundleAsync(scope);

        var bundle = await db.SepsisBundles.SingleAsync();
        bundle.DeadlineAt = DateTimeOffset.UtcNow.AddHours(-1);
        await db.SaveChangesAsync();

        var elements = await db.SepsisBundleElements.ToListAsync();
        foreach (var element in elements)
            await bundleService.OnOrderResultedAsync(element.OrderId!.Value);

        var updated = await db.SepsisBundles.AsNoTracking().SingleAsync();
        updated.ComplianceStatus.Should().Be(SepsisBundleComplianceStatus.NonCompliant);
        updated.CompletedAt.Should().NotBeNull();
    }

    [Fact]
    public async Task DeadlinePassed_MonitorMarksNonCompliant()
    {
        using var scope = _fixture.Services.CreateScope();
        var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();

        await CreateSofaSepsisBundleAsync(scope);

        var bundle = await db.SepsisBundles.SingleAsync();
        bundle.DeadlineAt = DateTimeOffset.UtcNow.AddHours(-1);
        await db.SaveChangesAsync();

        var monitor = new SepsisBundleMonitorService(
            _fixture.Services,
            _fixture.Services.GetRequiredService<ClinicalMetrics>(),
            _fixture.Services.GetRequiredService<ILogger<SepsisBundleMonitorService>>());

        await monitor.ScanOverdueBundlesAsync(CancellationToken.None);

        var updated = await db.SepsisBundles.AsNoTracking().SingleAsync();
        updated.ComplianceStatus.Should().Be(SepsisBundleComplianceStatus.NonCompliant);
        updated.CompletedAt.Should().BeNull(
            "the monitor marks overdue bundles non-compliant without setting CompletedAt — " +
            "elements are still incomplete");

        var elements = await db.SepsisBundleElements
            .AsNoTracking()
            .Where(e => e.BundleId == updated.Id)
            .ToListAsync();
        elements.Should().AllSatisfy(e =>
            e.Status.Should().Be(SepsisBundleElementStatus.Pending,
                "the monitor does not complete individual elements"));
    }
}