vigilcare-clinical/docs/clinical-testing-guide.md

# VigilCare Clinical Testing Guide

**For doctors and nurses evaluating the alerting dashboard**

This guide walks you through testing the VigilCare monitoring dashboard. You will review simulated patient scenarios, decide whether alerts are clinically meaningful, and record structured feedback that helps the team improve the system.

No programming knowledge is required. A facilitator will start the backend services and open the dashboard in your browser.

---

## Table of Contents

1. [What you are testing](#1-what-you-are-testing)
2. [Important notes before you start](#2-important-notes-before-you-start)
3. [Getting to the dashboard](#3-getting-to-the-dashboard)
4. [Tour of the application](#4-tour-of-the-application)
5. [Your core task — review and rate alerts](#5-your-core-task--review-and-rate-alerts)
6. [Understanding the six feedback ratings](#6-understanding-the-six-feedback-ratings)
7. [Recommended testing sessions](#7-recommended-testing-sessions)
8. [Scenario scripts](#8-scenario-scripts)
9. [Session checklist](#9-session-checklist)
10. [Submitting your feedback](#10-submitting-your-feedback)
11. [Frequently asked questions](#11-frequently-asked-questions)
12. [New dashboard features](#12-new-dashboard-features)

---

## 1. What you are testing

VigilCare is a **clinical decision support prototype**. It watches vital signs and lab-style observations for hospitalized patients and raises alerts when something looks wrong — for example:

- A single vital sign in a warning range (heart rate, blood pressure, temperature)
- A **NEWS2** early warning score crossing medium or high risk
- **SIRS / sepsis** or **qSOFA** patterns suggesting infection or organ dysfunction
- **Rapid deterioration** — a vital changing quickly even if still “in range”
- **Sepsis bundle** tracking — whether time-critical treatments were ordered and completed

The **dashboard** is where you, as a clinician, would see those alerts and decide what to do. This testing round adds **structured feedback**: after reviewing each alert, you tell us whether it would help or hinder real clinical work. The dashboard also includes a **department overview** for unit-level situational awareness, a **sepsis bundle board** tracking compliance deadlines in real time, **critical alert notifications** (audible + browser), **shift handoff reports** in SBAR format, and a **vitals entry form** for recording observations at the bedside.

Your ratings are the primary output of this study. There are no right or wrong answers — we want your honest clinical judgment on simulated cases.

---

## 2. Important notes before you start

### Simulated patients only

All patients in this test are **fictional**. Data is generated by a replay simulator, not from real bedside monitors. Treat it like a training exercise, not live clinical work.

### Not a production EHR

This dashboard is a **research and evaluation tool**. It does not replace your hospital’s charting system, does not send real pages, and does not write orders to a live pharmacy or lab.

### Acknowledge and resolve are practice actions

You can tap **Ack** and **Resolve** on alerts to walk through the workflow. In this environment those actions update the test database only.

### Feedback stays in your browser (for now)

Your ratings are saved in the browser on the computer you use. Export them at the end of the session (see [§10](#10-submitting-your-feedback)) and send the file to the study facilitator. If you switch computers or clear browser data without exporting, ratings may be lost.

### Default clinician ID

Acknowledging alerts uses a demo identifier (`DR-DEMO`) unless the facilitator configures yours. This does not affect your feedback ratings.

---

## 3. Getting to the dashboard

The facilitator will ensure the following are running. You only need the browser URL.

| What | Where |
|---|---|
| Dashboard | **http://localhost:5173** (or URL provided by facilitator) |
| Your role | Review alerts and submit feedback |

**On first open** you land on **Virtual Ward** — a list of active simulated patients sorted by acuity (NEWS2 score).

If the ward list is empty, ask the facilitator to start or replay a scenario (see [§8](#8-scenario-scripts)).

---

## 4. Tour of the application

Use the sidebar (desktop) or bottom navigation (mobile) to move between screens. The sidebar includes links to **Virtual Ward**, **Department Overview**, **Sepsis Bundle Board**, **Alert Center**, and **Feedback Summary**.

### Virtual Ward

**Purpose:** See who is on the floor and who needs attention first.

- Patients sorted by **NEWS2 score** by default — click any column header (Room, Patient, NEWS2, qSOFA, Sepsis, Alerts) to re-sort.
- Badge shows count of patients with NEWS2 ≥ 7.
- **Search bar** — type a patient name or MRN to find someone quickly.
- **Quick-filter toggles** — narrow the list to Critical (NEWS2 ≥ 7), Has Alerts, or Active Sepsis.
- Filter by department if asked (ICU, General Medicine, Surgery).
- **Click a patient row** to open their detail page.
- **Handoff Report** button in the toolbar generates a structured shift handoff for all visible patients (see [§12](#12-new-dashboard-features)).

**What to notice:** Does the sort order match how you would prioritize a real ward round? Are the search and filters useful for finding patients quickly?

---

### Patient Detail

**Purpose:** Deep review of one patient — vitals, scores, alerts, trends, and why alerts fired.

| Section | What it shows |
|---|---|
| **Scores** | Current NEWS2 total and risk level, SOFA score with organ-system breakdown, GCS total and component scores |
| **Latest Vitals** | Most recent heart rate, RR, BP, SpO₂, temperature, etc. |
| **Vitals Entry** | Record new vital signs manually (7 parameters with AVPU dropdown) — plausibility-validated before submission |
| **Active Alerts** | Open alerts for this patient — **click a row** to see reasoning |
| **Alert reasoning** | Plain-language explanation of why the alert fired; may show recent medications |
| **Orders** | Clinical orders (labs, antibiotics, fluids, etc.) |
| **Sepsis bundle** | If sepsis was suspected — four time-critical elements and compliance status |
| **Vital sign charts** | Trends for HR, RR, systolic BP, SpO₂, temperature — with medication administration markers |
| **NEWS2 history** | How the early warning score changed over time |
| **SOFA / GCS / qSOFA history** | Organ-system breakdown over time, component tracking, evaluation history |
| **Patient banner** | Demographics, age, blood type, allergies, emergency contact |
| **Encounter timeline** | Merged chronological view of status changes, observation summaries, and alerts |
| **Replay controls** | Local timeline bar (pause, speed, **Next Alert →**) — scrubs charts/vitals to a point in time; does not control the simulator |

**What to notice:** Would you trust these charts and explanations during a real handoff? Is the vitals entry form intuitive? Is anything missing?

---

### Alert Center

**Purpose:** Hospital-wide inbox — all alerts across patients, not just one encounter.

- Tabs: **Open**, **Acknowledged**, **Resolved**, **Escalated**.
- Each card shows severity, type, details, and time.
- **Ack** opens a role-aware acknowledgment modal — your name and role are pre-filled from your login, with a preview of the acknowledgment note. Add optional clinical notes before confirming.
- **Resolve** (must be acknowledged first).
- **Critical alert banner** — when new critical alerts arrive (detected during polling), a banner appears at the top of the page with an audible tone and browser notification. You can dismiss individual alerts or all at once.
- **Feedback buttons** on every card (see [§5](#5-your-core-task--review-and-rate-alerts)).

**What to notice:** Is it easy to triage multiple patients from one screen? Is the critical alert notification helpful or distracting? Would you use this during a shift?

---

### Department Overview

**Purpose:** Bird's-eye view of all departments — which units are busiest and which need attention.

- Summary cards show **total active patients**, **critical count** (NEWS2 ≥ 7), **open alerts**, and **active sepsis bundles** across the hospital.
- One card per department with patient count, acuity distribution bar, alert count, and bundle count.
- **Click a department card** to jump to the Virtual Ward filtered to that unit.
- Polls every 10 seconds for live updates.

**What to notice:** Would this view help a charge nurse or bed manager allocate resources? Does the acuity breakdown feel clinically useful?

---

### Sepsis Bundle Board

**Purpose:** Track all active sepsis bundles hospital-wide with countdown timers to the 1-hour compliance deadline.

- Each bundle row shows patient name/MRN, room, department, recognition time, countdown timer, compliance status, and element progress (how many of the four treatment elements are complete).
- Bundles are sorted by urgency: **overdue** (past deadline, red) → **at risk** (< 15 minutes remaining, amber) → **on track** (green).
- Countdown updates every second.
- Summary line shows total bundles and breakdown by urgency category.

**What to notice:** Is the urgency sorting intuitive? Would real-time countdown timers help your team meet sepsis compliance targets?

---

### Feedback Summary

**Purpose:** Aggregate view of all ratings you (and others on the same browser) have submitted.

- **Total ratings**, **% useful / would act**, **% false positive**, **timing issues**.
- Breakdown **by alert type** (e.g. sepsis, NEWS2, heart rate warning).
- **Recent feedback** list with your notes.
- **Export JSON** and **Export CSV** — use CSV for spreadsheets.

Open this at the end of a session to sanity-check your work before export.

---

## 5. Your core task — review and rate alerts

For **each alert** you review, complete this short workflow:

```
1. Read the alert (severity, type, details, time)
2. Optional: open Patient Detail → click the alert → read "why it fired"
3. Optional: look at vitals, charts, medications, sepsis bundle
4. Choose ONE feedback rating (required for that alert)
5. Optional: tap "+ Note" and add a short clinical comment
6. Move to the next alert
```

### Where feedback buttons appear

- **Alert Center** — below each alert card.
- **Patient Detail** — below the alert reasoning panel (after you click an alert).
- **Active Alerts list** — on expanded reasoning view when integrated.

You can rate alerts in any status (Open, Acknowledged, Resolved, Escalated). You may **change your rating** by selecting a different button — the latest choice replaces the previous one.

### Tips for consistent ratings

- Rate based on what you knew **at the time the alert fired**, using the charts and reasoning as context — not hindsight after the full scenario finished.
- If an alert was technically correct but **not actionable**, consider **Too early**, **Too late**, or **Missing context** rather than Useful.
- If the patient was stable and the alert reflected expected treatment (e.g. beta-blocker bradycardia), **False positive** or **Missing context** may fit better than Useful.
- Use **Would act** when you would genuinely change management based on that notification alone.

---

## 6. Understanding the six feedback ratings

| Button | When to use it | Example |
|---|---|---|
| **Useful** | Clinically appropriate alert; right concern at right time | NEWS2 rises to 6 as RR and HR worsen in sepsis scenario |
| **Would act** | You would change assessment, monitoring, or treatment because of this alert | qSOFA alert on a patient you would escalate to senior review |
| **Too early** | Directionally right but fired before you would act | Warning HR while patient still asymptomatic and trending stable |
| **Too late** | Real problem existed but alert came after you would have intervened | Deterioration alert after you would already have called a rapid response |
| **False positive** | Alert should not have fired for this patient context | Bradycardia warning on a patient on scheduled metoprolol with baseline low HR |
| **Missing context** | Alert may be valid but message lacks information you need | HR warning without noting recent beta-blocker dose |

### Optional notes — what to write

Short phrases are enough. Examples:

- *"Expected bradycardia — patient on metoprolol 25 mg PO"*
- *"Would have acted on NEWS2 ≥ 7 sooner if bundle status visible"*
- *"Useful but duplicate of HR warning 10 min earlier"*
- *"Needed lactate trend, not just single value"*

---

## 7. Recommended testing sessions

### Session A — Quick orientation (20–30 minutes)

**Goal:** Learn the UI and rate at least 5 alerts.

1. Facilitator replays `stable-baseline-01` — confirm ward stays quiet or low acuity.
2. Facilitator replays `uti-sepsis-elderly-01` at faster speed.
3. You: Virtual Ward → open patient → review 2–3 alerts with reasoning + charts.
4. You: Alert Center → rate remaining alerts.
5. Feedback Summary → export CSV.

### Session B — Alert quality deep dive (45–60 minutes)

**Goal:** Compare alert types across scenarios.

1. `medication-false-alarm-01` — focus on false positives and missing context.
2. `uti-sepsis-elderly-01` — sepsis, NEWS2, bundle panel.
3. `respiratory-failure-asthma-01` or `post-op-hemorrhage-01` — deterioration patterns.
4. Export CSV with notes on at least 10 alerts.

### Session C — Ward workflow (30 minutes)

**Goal:** Test prioritization and handoff usability.

1. Facilitator runs `replay-all` on the scenario folder (or 2–3 scenarios back-to-back).
2. You: Stay on Virtual Ward — note sort order as new patients appear.
3. Try sorting by different columns (qSOFA, Alerts, Sepsis) — which view is most useful?
4. Use the search bar and quick filters to narrow the list.
5. Round on each high-NEWS2 patient — detail page only, no Alert Center until end.
6. Generate a **Handoff Report** and review the SBAR content for each patient.
7. Document: *Would this order match your morning ward round? Is the handoff report format useful?*

### Session D — New features deep dive (30–45 minutes)

**Goal:** Evaluate the new dashboard features for clinical usefulness.

1. Facilitator replays 3–4 scenarios (including `uti-sepsis-elderly-01` for sepsis bundles).
2. Open **Department Overview** — review the unit-level cards and summary stats.
3. Open **Sepsis Bundle Board** — watch countdown timers and urgency sorting.
4. Return to **Virtual Ward** — test the search bar, quick filters, and column sorting.
5. Open a patient → use the **Vitals Entry form** to record manual observations.
6. Wait for a critical alert → note the **critical alert banner**, sound, and browser notification.
7. Acknowledge an alert using the new **role-aware modal** — review the note preview.
8. Generate a **Handoff Report** and review the SBAR format.
9. Document: *Which new features would you use on a real ward? Which need improvement?*

---

## 8. Scenario scripts

The facilitator runs these from a separate terminal. You watch the dashboard update.

| Scenario | Clinical story | What to evaluate |
|---|---|---|
| `stable-baseline-01.json` | Stable inpatient, minimal abnormal vitals | Alert noise — should few or no alerts fire? |
| `medication-false-alarm-01.json` | Beta-blocker, baseline low HR, boundary vitals | False alarms, alert fatigue, medication context in reasoning |
| `uti-sepsis-elderly-01.json` | Elderly UTI progressing to sepsis | SIRS/qSOFA, NEWS2 trend, sepsis bundle, usefulness of escalation |
| `respiratory-failure-asthma-01.json` | Asthma exacerbation | RR/SpO₂ warnings, NEWS2, rapid deterioration |
| `post-op-hemorrhage-01.json` | Post-operative bleeding | BP/HR trends, critical vs warning timing |
| `cardiac-arrest-post-mi-01.json` | Post-MI deterioration | High-acuity alerts, would-act vs too-late |
| `dka-electrolyte-01.json` | Metabolic emergency | Multi-parameter scoring, order visibility |
| `hypothermia-elderly-01.json` | Temperature-driven risk | Temp warnings, NEWS2 contribution |

**Facilitator command (example):**

```bash
dotnet run --project VigilCare.Simulator -- replay \
  VigilCare.Simulator/Scenarios/List/uti-sepsis-elderly-01.json \
  --speed 60
```

`--speed 60` means 60× real time — a 3-hour scenario completes in a few minutes. Ask the facilitator to pause between scenarios if you need more review time.

---

## 9. Session checklist

Use this during or after your session.

### Virtual Ward
- [ ] Patient list loads and refreshes
- [ ] NEWS2 sort order feels clinically sensible
- [ ] Clicking column headers (Room, Patient, NEWS2, qSOFA, Sepsis, Alerts) changes sort order
- [ ] Patient search by name or MRN works
- [ ] Quick filters (Critical, Has Alerts, Active Sepsis) narrow the list correctly
- [ ] Department filter works (if tested)
- [ ] Patient detail opens from row click
- [ ] Handoff Report generates and displays correctly (test print/PDF if possible)

### Patient Detail
- [ ] Latest vitals match what you expect for the scenario
- [ ] NEWS2 score and risk level display correctly
- [ ] SOFA score with organ-system breakdown visible
- [ ] GCS score with component breakdown visible
- [ ] Vitals Entry form validates values and submits successfully
- [ ] Clicking an alert shows reasoning panel
- [ ] Medication context appears when relevant (beta-blocker scenario)
- [ ] Vital sign charts show sensible trends (with medication markers where applicable)
- [ ] NEWS2 history chart updates over time
- [ ] SOFA / GCS / qSOFA history charts update over time
- [ ] Patient banner shows demographics, allergies, emergency contact
- [ ] Encounter timeline shows chronological events
- [ ] Sepsis bundle panel appears when sepsis alerts fire
- [ ] **Next Alert →** selects each open alert, scrubs charts to that time, and scrolls the review section into view

### Alert Center
- [ ] Open / Acknowledged / Resolved tabs filter correctly
- [ ] Acknowledge modal shows your name and role, note preview works
- [ ] Acknowledge and resolve workflow understandable
- [ ] Critical alert banner appears for new critical alerts (with sound if not muted)
- [ ] Feedback buttons visible on every card

### Department Overview
- [ ] Summary cards show total patients, critical count, alerts, bundles
- [ ] Department cards load with acuity bars
- [ ] Clicking a department navigates to ward filtered by that unit

### Sepsis Bundle Board
- [ ] Active bundles listed with countdown timers
- [ ] Urgency sorting (overdue → at risk → on track) feels correct
- [ ] Countdown timer updates in real time

### Feedback (Phase 19)
- [ ] Rated at least **5 alerts** (more is better)
- [ ] Used more than one rating category (not all “Useful”)
- [ ] Added notes on at least **2** alerts where context mattered
- [ ] Changed a rating intentionally — confirm new selection sticks after refresh
- [ ] Feedback Summary totals look correct
- [ ] Exported **CSV** (and JSON if requested)

### Overall clinical judgment
- [ ] Which alert types were most trustworthy?
- [ ] Which caused unnecessary noise?
- [ ] What information was missing from alert text or reasoning?
- [ ] Was the department overview useful for situational awareness?
- [ ] Was the sepsis bundle board useful for compliance tracking?
- [ ] Was the handoff report format (SBAR) clinically appropriate?
- [ ] Were critical alert notifications helpful or disruptive?
- [ ] Would you want this on a real ward? Why or why not?

---

## 10. Submitting your feedback

At the end of your session:

1. Open **Feedback Summary** (sidebar → Feedback).
2. Review totals and recent entries.
3. Click **Export CSV**.
4. Save the file (e.g. `vigilcare-feedback-dr-smith-2026-06-20.csv`).
5. Send to the facilitator via the method they specify (email, shared drive, study portal).

The CSV contains: alert ID, alert type, severity, your rating, notes, and timestamp. The research team aggregates exports from all participants.

**Optional:** Export JSON if the facilitator requests machine-readable format.

**Same computer:** Ratings persist if you refresh the page on the same browser. **Different computer:** Export before switching devices.

---

## 11. Frequently asked questions

**I don’t see any patients.**  
The simulator may not have run yet, or all encounters are discharged. Ask the facilitator to replay a scenario.

**Charts are empty but vitals show data.**  
Wait a few seconds — the page polls every 5 seconds. If charts stay empty, tell the facilitator.

**Can I rate the same alert twice?**  
You can change your rating; only the latest is kept per alert.

**Do I have to acknowledge before rating?**  
No. Rate any alert in any status.

**What’s the difference between Useful and Would act?**  
*Useful* = good alert clinically. *Would act* = you would specifically change care because of it. An alert can be useful information but not change your plan — use the button that best matches your reasoning.

**The replay bar doesn’t pause the simulator.**  
Correct — replay controls scrub observation/chart data already loaded in the browser (pause, speed, and **Next Alert →** move a local timeline). The facilitator controls simulator speed separately.

**The alert sound is annoying — can I turn it off?**  
Yes. Click the sound toggle icon in the header bar to mute critical alert tones. The visual banner and browser notifications still appear.

**How do I print the handoff report?**  
Open the Handoff Report from the Virtual Ward toolbar, then click **Print / Save PDF**. The report is formatted for printing — the overlay and controls are hidden in print view.

**Can I record vitals from the dashboard?**  
Yes. On any Patient Detail page, use the **Vitals Entry** section to enter vital signs. Values are validated before submission and processed by the same scoring engines as device data.

**What is the Sepsis Bundle Board?**  
A hospital-wide view of all active sepsis bundles with live countdown timers. It helps track whether the four required treatment elements (blood cultures, lactate, antibiotics, fluids) are completed within the 1-hour compliance window.

**Dark mode?**  
Toggle in the header if your eyes prefer it; all screens support dark mode.

**Who do I contact with problems?**  
Speak to your session facilitator. Technical issues (blank screen, errors) may need them to restart the API or dashboard.

---

## Quick reference card

| I want to… | Go to… |
|---|---|
| See all patients by acuity | Virtual Ward |
| Find a specific patient | Virtual Ward → search bar (name or MRN) |
| See only critical patients | Virtual Ward → Critical quick-filter toggle |
| Deep-dive one patient | Click patient → Patient Detail |
| Record vital signs manually | Patient Detail → Vitals Entry form |
| See all departments at a glance | Department Overview (sidebar) |
| Track sepsis bundle compliance | Sepsis Bundle Board (sidebar) |
| Triage all hospital alerts | Alert Center |
| Understand why an alert fired | Patient Detail → click alert → Reasoning |
| Acknowledge an alert | Alert Center or Patient Detail → Ack button → modal |
| Rate an alert | Feedback buttons under alert card or reasoning |
| See my ratings aggregate | Feedback Summary |
| Generate a shift handoff | Virtual Ward → Handoff Report button |
| Submit results | Feedback Summary → Export CSV |

---

## 12. New dashboard features

This section summarizes features added after the initial dashboard release. If you are already familiar with the basic workflow (ward → patient detail → alerts → feedback), read this section for what is new.

### Sortable ward table

The ward table now supports **column sorting**. Click any column header (Room, Patient, Department, NEWS2, qSOFA, Sepsis, Alerts) to sort by that column. Click again to reverse direction. The default remains NEWS2 descending (most acute first). A secondary sort by NEWS2 breaks ties when sorting by other columns.

### Patient search and quick filters

A **search bar** at the top of the ward lets you type a patient name or MRN to find someone instantly. Three **quick-filter toggles** narrow the list:
- **Critical** — only patients with NEWS2 ≥ 7
- **Has Alerts** — only patients with open alerts
- **Active Sepsis** — only patients with an active sepsis bundle or SOFA_SEPSIS alert

A "Clear filters" button resets all filters and search.

### Department Overview (`/departments`)

A new **Department Overview** page (accessible from the sidebar) provides a bird's-eye view of the hospital. Summary cards at the top show total active patients, critical count, open alerts, and active sepsis bundles. Below, one card per department shows its patient count, acuity distribution (a visual bar), and alert/bundle counts. Click a department card to navigate to the ward filtered to that unit.

### Sepsis Bundle Board (`/sepsis`)

A new **Sepsis Bundle Board** page tracks all active sepsis bundles hospital-wide. Each bundle row shows the patient, room, department, recognition time, a **live countdown timer** to the 1-hour compliance deadline, and element completion progress. Bundles are color-coded and sorted by urgency: **overdue** (past deadline) → **at risk** (< 15 minutes remaining) → **on track**. The countdown updates every second.

### Critical alert notifications

When the dashboard detects new critical alerts during its polling cycle, a **critical alert banner** appears at the top of the page. It includes:
- An **audible two-tone alert** (can be muted via the sound toggle in the header)
- A **flashing browser title** (`⚠ CRITICAL ALERT — VigilCare`)
- A **browser notification** (if you grant notification permission when prompted)

Dismiss individual alerts or all at once. The banner does not replace the Alert Center — it highlights new critical arrivals so you do not miss them.

### Shift handoff report

The **Handoff Report** button on the Virtual Ward toolbar generates a structured shift handoff document for all visible patients (respecting any active filters). The report includes:

- **Ward summary** — department, patient count, critical count, open alerts, active bundles
- **Per-patient SBAR** — Situation (admission reason), Background (allergies), Assessment (scores + latest vitals + open alerts), Recommendation (pending orders + sepsis bundle status)
- **Scores overview** — NEWS2, SOFA (with delta), GCS, qSOFA per patient

Use **Print / Save PDF** to export the report for paper handoff or archive.

### Vitals entry form

On the **Patient Detail** page, a **Vitals Entry** section lets you manually record observations for seven vital parameters: Heart Rate, Respiratory Rate, Systolic BP, Diastolic BP, SpO₂, Temperature, and AVPU (as a dropdown). Values are validated against plausibility ranges before submission. At least one vital sign must be entered. This simulates bedside manual charting — observations posted through this form are processed by the same scoring engines as device-generated data.

### Role-aware alert acknowledgment

The **Ack** button now opens a modal that shows:
- Your name and role (from your login session)
- Role-specific guidance (e.g. "You are acknowledging as a nurse — documenting awareness of this alert")
- A preview of the acknowledgment note that will be recorded
- An optional text field for additional clinical notes

This makes the acknowledgment workflow more realistic and tracks who acknowledged what.

---

*Thank you for participating. Your clinical feedback directly shapes whether VigilCare alerts help or harm real ward workflows.*