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1. Ward deterioration huddle

Acute medical ward, 20 inpatients, evening safety huddle. Charted observations plus the nurse's latest progress note.

Question: can Jev read the nursing note for the signals that NEWS2 misses, while code keeps doing the arithmetic?

flowchart LR
  V[Charted vitals<br/>FHIR Observation] --> N[NEWS2 in code]
  T[Nursing note<br/>FHIR DocumentReference] --> J{Jev: 4 questions<br/>1 request}
  J -- "Noul: new confusion" --> N
  J -- "Score: concern" --> B[Escalation band<br/>max of NEWS2 band, concern]
  N --> B
  J -- "Noul: infection" --> S[Sepsis screen prompt]
  J -- "Choice: pattern" --> P[Next-step bundle]
  B --> R[Ranked huddle list]
Question Primitive Task category How the answer is used
New change in mental state vs baseline? Noul Detection If the chart says Alert, a yes becomes Confusion (3 NEWS2 points)
Infection signs or suspicion? Noul Detection With NEWS2 ≥ 5, prompts a sepsis screen
How worried should the team be? Score (4 levels) Scoring → Ranking Floor on the escalation band; weight in the priority sort
Main type of deterioration? Choice (9 options) Classification Selects the next-step bundle (sepsis, ECG/troponin, CT head…)
Exact questions sent to Jev 
{
  "new_confusion": {
    "type": "noul",
    "instructions": "Does `nursing_note` describe a new change in the patient's mental state or level of consciousness compared with their usual baseline, such as new confusion, disorientation, agitation, hallucinations, drowsiness or reduced responsiveness?",
    "criteria": {
      "true": "A change from the patient's usual mental state is described, even if they have dementia or a learning disability at baseline.",
      "false": "Mental state is normal, or unchanged from a known baseline such as long-standing dementia that is as usual."
    }
  },
  "infection": {
    "type": "noul",
    "instructions": "Does `nursing_note` describe signs of a current infection, an infection being treated, or a suspicion of infection?",
    "criteria": {
      "true": "For example fever, rigors, purulent sputum, urinary symptoms, spreading redness, or an infection under treatment.",
      "false": "No infection signs are described, or infection is explicitly ruled out."
    }
  },
  "concern": {
    "type": "score",
    "instructions": "How worried should the ward team be about this patient right now, based on `nursing_note`?",
    "criteria": [
      "Stable or improving, no new problems; routine care",
      "A minor issue to keep monitoring, with no clinical review needed today",
      "A worrying change that needs a doctor to assess within the hour, such as a behaviour change, an event that has since resolved, or family saying the patient is not themselves",
      "Acute deterioration happening now that needs immediate senior review or the rapid response team"
    ]
  },
  "pattern": {
    "type": "choice",
    "instructions": "What is the main type of clinical deterioration described in `nursing_note`?",
    "criteria": {
      "sepsis_infection": "Infection causing systemic illness: fever or rigors with fast heart rate, low blood pressure, new confusion or low urine output",
      "respiratory": "Worsening breathing, rising oxygen requirement or low oxygen saturation",
      "cardiac": "Chest pain, arrhythmia, or collapse from a heart cause",
      "neurological": "Stroke, head injury, seizure, delirium, or reduced consciousness from a brain cause",
      "bleeding": "Blood loss, such as black stools, vomiting blood, or bleeding with falling blood pressure",
      "metabolic_renal": "Blood sugar, electrolyte, calcium, fluid balance or kidney problems",
      "drug_or_substance": "Medication toxicity, over-sedation, or alcohol or drug withdrawal",
      "other": "A concerning change that fits none of the other options",
      "no_acute_change": "No deterioration: stable, improving, or at baseline"
    }
  }
}

Results

20 requests, 80 questions (4 per request) · latency p50 334 ms, p95 588 ms · 21,924 input / 3,113 output tokens · $0.0009

Question Primitive n Result vs reference
new_confusion Noul 20 accuracy 100% (unambiguous 100%), Brier 0.009
infection Noul 20 accuracy 90% (unambiguous 100%), Brier 0.002
concern Score 20 exact level 85%, MAE 0.18
pattern Choice 20 accuracy 95% (primary label 85%)

Does Jev add anything to NEWS2?

Policy Band matches reference Under-triaged Over-triaged
NEWS2 from charted obs only 50% 10 / 20 0
NEWS2 + Jev (confusion → ACVPU, concern floor) 95% 1 / 20 0

NEWS2 alone under-triaged 10 patients. All of them had the key signal only in the note: ongoing ischaemic chest pain, melaena with a NEWS2 of 4, alcohol withdrawal with hallucinations, an anticoagulated fall patient becoming unrousable, undocumented delirium, a daughter saying "she's not herself", a non-verbal patient's carer reporting a change, a transient bradycardic syncope, a GCS drop from 15 to 14 on head-injury obs, and blood sugars of 14–18 in a diabetic foot infection. The ranking puts 7 of the 8 reference emergencies in the top 8.

Literal-reading check: for the patient with long-standing Alzheimer's who is "pleasantly confused… no change from his baseline", Jev returned new-confusion = 0.03. For the patient with Alzheimer's plus new delirium, it returned 0.97. The negation-heavy note ("No chest pain. No shortness of breath. No confusion…") returned 0.04.

Ranked huddle list (all 20 patients)
Admission NEWS2 charted Jev confusion NEWS2 + Jev Jev concern Jev pattern NEWS2-only band Final band Reference
Community-acquired pneumonia 10 0.91 13 2.96 respiratory emergency emergency emergency
Pyelonephritis, day 2 8 0.94 11 2.91 sepsis_infection emergency emergency emergency
Acute kidney injury on CKD stage 3 8 0.90 8 3.00 drug_or_substance emergency emergency emergency
NSTEMI, day 2 4 0.91 7 2.44 drug_or_substance ward_review emergency emergency
Chest infection; on warfarin for AF 4 0.06 4 2.85 bleeding ward_review emergency emergency
Unwitnessed fall at home, on warfarin for AF 3 0.98 3 2.99 neurological urgent_review emergency emergency
NSTEMI, awaiting angiography 3 0.04 3 2.72 cardiac ward_review emergency emergency
Fractured neck of femur, post-op day 2 hemiarthroplasty 2 0.97 5 2.24 neurological ward_review urgent_review urgent_review
Hypercalcaemia secondary to multiple myeloma, on IV fluids 2 0.88 5 2.03 other ward_review urgent_review urgent_review
Fall at home, no injury, awaiting OT assessment 1 0.79 4 2.00 neurological ward_review urgent_review urgent_review
Fall with head strike, head injury observations 0 0.92 3 2.46 neurological routine urgent_review ⬇ emergency
Infective exacerbation of COPD, day 4 of antibiotics 5 0.03 5 0.01 no_acute_change urgent_review urgent_review urgent_review
Syncope under investigation, on telemetry 0 0.33 0 2.00 cardiac routine urgent_review urgent_review
Acute asthma, day 2 2 0.03 2 0.35 no_acute_change ward_review ward_review ward_review
Diabetic foot cellulitis, on IV antibiotics 0 0.03 0 0.79 no_acute_change routine ward_review ward_review
Right total knee replacement, post-op day 1 1 0.03 1 0.01 no_acute_change ward_review ward_review ward_review
Community-acquired pneumonia, day 4 0 0.04 0 0.07 no_acute_change routine routine routine
Elective admission for respite and medication review 0 0.03 0 0.03 no_acute_change routine routine routine
Inferior STEMI, day 3 post primary PCI 0 0.03 0 0.01 no_acute_change routine routine routine
Dehydration and AKI after gastroenteritis 0 0.03 0 0.01 no_acute_change routine routine routine

⬇ under-triaged vs reference · ⬆ over-triaged

The only band error is the head-injury patient: concern 2.46 rounded down to urgent when the reference is emergency. Rounding a fractional Score is a policy choice. Using ceil above x.4 for this question would have caught it, but I did not tune thresholds on this data.