医疗 CDSS 开发模式¶

用于构建集成到 EMR 工作流中的临床决策支持系统的模式。CDSS 模块关乎患者安全，至关重要——对假阴性零容忍。

使用场景¶

实现药物相互作用检查
构建剂量验证引擎
实现临床评分系统（NEWS2、qSOFA、APACHE、GCS）
设计异常临床值警报系统
构建带安全检查的用药医嘱录入
将实验室结果解读与临床情境集成

工作原理¶

CDSS 引擎是一个零副作用的纯函数库。输入临床数据，输出警报。这使得它完全可以测试。

三个主要模块：

checkInteractions(newDrug, currentMeds, allergies) — 将新药与当前用药和已知过敏史进行核对。返回按严重程度排序的 InteractionAlert[]。使用 DrugInteractionPair 数据模型。
validateDose(drug, dose, route, weight, age, renalFunction) — 根据基于体重、年龄调整和肾功能调整的规则验证处方剂量。返回 DoseValidationResult。
calculateNEWS2(vitals) — 根据 NEWS2Input 计算英国国家早期预警评分 2（National Early Warning Score 2）。返回包含总分、风险级别和升级指导的 NEWS2Result。

EMR UI
  ↓ (user enters data)
CDSS Engine (pure functions, no side effects)
  ├── Drug Interaction Checker
  ├── Dose Validator
  ├── Clinical Scoring (NEWS2, qSOFA, etc.)
  └── Alert Classifier
  ↓ (returns alerts)
EMR UI (displays alerts inline, blocks if critical)

药物相互作用检查¶

interface DrugInteractionPair {
  drugA: string;           // generic name
  drugB: string;           // generic name
  severity: 'critical' | 'major' | 'minor';
  mechanism: string;
  clinicalEffect: string;
  recommendation: string;
}

function checkInteractions(
  newDrug: string,
  currentMedications: string[],
  allergyList: string[]
): InteractionAlert[] {
  if (!newDrug) return [];
  const alerts: InteractionAlert[] = [];
  for (const current of currentMedications) {
    const interaction = findInteraction(newDrug, current);
    if (interaction) {
      alerts.push({ severity: interaction.severity, pair: [newDrug, current],
        message: interaction.clinicalEffect, recommendation: interaction.recommendation });
    }
  }
  for (const allergy of allergyList) {
    if (isCrossReactive(newDrug, allergy)) {
      alerts.push({ severity: 'critical', pair: [newDrug, allergy],
        message: `Cross-reactivity with documented allergy: ${allergy}`,
        recommendation: 'Do not prescribe without allergy consultation' });
    }
  }
  return alerts.sort((a, b) => severityOrder(a.severity) - severityOrder(b.severity));
}

相互作用对必须是双向的：如果药物 A 与药物 B 存在相互作用，那么药物 B 也与药物 A 存在相互作用。

剂量验证¶

interface DoseValidationResult {
  valid: boolean;
  message: string;
  suggestedRange: { min: number; max: number; unit: string } | null;
  factors: string[];
}

function validateDose(
  drug: string,
  dose: number,
  route: 'oral' | 'iv' | 'im' | 'sc' | 'topical',
  patientWeight?: number,
  patientAge?: number,
  renalFunction?: number
): DoseValidationResult {
  const rules = getDoseRules(drug, route);
  if (!rules) return { valid: true, message: 'No validation rules available', suggestedRange: null, factors: [] };
  const factors: string[] = [];

  // SAFETY: if rules require weight but weight missing, BLOCK (not pass)
  if (rules.weightBased) {
    if (!patientWeight || patientWeight <= 0) {
      return { valid: false, message: `Weight required for ${drug} (mg/kg drug)`,
        suggestedRange: null, factors: ['weight_missing'] };
    }
    factors.push('weight');
    const maxDose = rules.maxPerKg * patientWeight;
    if (dose > maxDose) {
      return { valid: false, message: `Dose exceeds max for ${patientWeight}kg`,
        suggestedRange: { min: rules.minPerKg * patientWeight, max: maxDose, unit: rules.unit }, factors };
    }
  }

  // Age-based adjustment (when rules define age brackets and age is provided)
  if (rules.ageAdjusted && patientAge !== undefined) {
    factors.push('age');
    const ageMax = rules.getAgeAdjustedMax(patientAge);
    if (dose > ageMax) {
      return { valid: false, message: `Exceeds age-adjusted max for ${patientAge}yr`,
        suggestedRange: { min: rules.typicalMin, max: ageMax, unit: rules.unit }, factors };
    }
  }

  // Renal adjustment (when rules define eGFR brackets and eGFR is provided)
  if (rules.renalAdjusted && renalFunction !== undefined) {
    factors.push('renal');
    const renalMax = rules.getRenalAdjustedMax(renalFunction);
    if (dose > renalMax) {
      return { valid: false, message: `Exceeds renal-adjusted max for eGFR ${renalFunction}`,
        suggestedRange: { min: rules.typicalMin, max: renalMax, unit: rules.unit }, factors };
    }
  }

  // Absolute max
  if (dose > rules.absoluteMax) {
    return { valid: false, message: `Exceeds absolute max ${rules.absoluteMax}${rules.unit}`,
      suggestedRange: { min: rules.typicalMin, max: rules.absoluteMax, unit: rules.unit },
      factors: [...factors, 'absolute_max'] };
  }
  return { valid: true, message: 'Within range',
    suggestedRange: { min: rules.typicalMin, max: rules.typicalMax, unit: rules.unit }, factors };
}

临床评分：NEWS2¶

interface NEWS2Input {
  respiratoryRate: number; oxygenSaturation: number; supplementalOxygen: boolean;
  temperature: number; systolicBP: number; heartRate: number;
  consciousness: 'alert' | 'voice' | 'pain' | 'unresponsive';
}
interface NEWS2Result {
  total: number;           // 0-20
  risk: 'low' | 'low-medium' | 'medium' | 'high';
  components: Record<string, number>;
  escalation: string;
}

评分表必须与 Royal College of Physicians 的规范完全一致。

警报严重级别与界面行为¶

严重级别	界面行为	需要临床医生采取的操作
严重	阻止操作。不可关闭的模态框。红色。	必须记录覆盖原因才能继续
主要	内联警告横幅。橙色。	必须确认后才能继续
次要	内联信息提示。黄色。	仅需知悉，无需操作

严重警报绝不能自动消失或以 toast 通知的形式实现。覆盖原因必须存储在审计跟踪中。

测试 CDSS（对漏报零容忍）¶

describe('CDSS — Patient Safety', () => {
  INTERACTION_PAIRS.forEach(({ drugA, drugB, severity }) => {
    it(`detects ${drugA} + ${drugB} (${severity})`, () => {
      const alerts = checkInteractions(drugA, [drugB], []);
      expect(alerts.length).toBeGreaterThan(0);
      expect(alerts[0].severity).toBe(severity);
    });
    it(`detects ${drugB} + ${drugA} (reverse)`, () => {
      const alerts = checkInteractions(drugB, [drugA], []);
      expect(alerts.length).toBeGreaterThan(0);
    });
  });
  it('blocks mg/kg drug when weight is missing', () => {
    const result = validateDose('gentamicin', 300, 'iv');
    expect(result.valid).toBe(false);
    expect(result.factors).toContain('weight_missing');
  });
  it('handles malformed drug data gracefully', () => {
    expect(() => checkInteractions('', [], [])).not.toThrow();
  });
});

通过标准：100%。哪怕只漏掉一次相互作用，也是一起患者安全事件。

反模式¶

在没有记录原因的情况下将 CDSS 检查设为可选项或可跳过
使用 toast 通知实现相互作用检查
对药物或临床数据使用 any 类型
硬编码相互作用对，而不使用可维护的数据结构
在 CDSS 引擎中静默捕获错误（必须以明显的方式暴露失败）
在体重不可用时跳过基于体重的验证（必须阻止，而不是放行）

示例¶

示例 1：药物相互作用检查¶

const alerts = checkInteractions('warfarin', ['aspirin', 'metformin'], ['penicillin']);
// [{ severity: 'critical', pair: ['warfarin', 'aspirin'],
//    message: 'Increased bleeding risk', recommendation: 'Avoid combination' }]

示例 2：剂量验证¶

const ok = validateDose('paracetamol', 1000, 'oral', 70, 45);
// { valid: true, suggestedRange: { min: 500, max: 4000, unit: 'mg' } }

const bad = validateDose('paracetamol', 5000, 'oral', 70, 45);
// { valid: false, message: 'Exceeds absolute max 4000mg' }

const noWeight = validateDose('gentamicin', 300, 'iv');
// { valid: false, factors: ['weight_missing'] }

示例 3：NEWS2 评分¶

const result = calculateNEWS2({
  respiratoryRate: 24, oxygenSaturation: 93, supplementalOxygen: true,
  temperature: 38.5, systolicBP: 100, heartRate: 110, consciousness: 'voice'
});
// { total: 13, risk: 'high', escalation: 'Urgent clinical review. Consider ICU.' }

本页原文 Markdown：在 AtomGit 查看·内容源自开源项目 ev/ECC