Automated video-based AVPU assessment within a FHIR-enabled clinical decision support framework

Accurate and timely assessment of consciousness is critical for triage, escalation of care, and patient safety in emergency and hospital settings. However, documentation using the AVPU scale (Alert, Verbal, Pain, Unresponsive) remains inconsistent owing to high workload, subjectivity, and fragmented workflows. This study developed and evaluated Consc.ia, a video-based clinical decision-support platform that automates AVPU inference while preserving clinician oversight and enabling seamless, interoperable documentation through HL7 FHIR. A simulated AVPU dataset comprising 136 videos from 58 healthcare professionals (physicians, nurses, paramedics, and first responders) was created under controlled conditions with ethics approval from the ISCTE - Instituto Universitário de Lisboa Ethics Commission (reference CE-ISTA/2025.08, July 2025). The system architecture combines edge-computing computer vision for real-time extraction of facial landmarks, eye state, arm movement, and verbal responses; a clinician-in-the-loop validation layer; and FHIR-mapped Observation resources for direct EHR integration. Three deployment scenarios (Emergency Medical Services, Emergency Departments, and Intermediate Care wards) were designed and compared. Technology adoption was modelled using Rogers' Innovation Adoption Curve and the Bass Diffusion Model (p = 0.01, q = 0.35, M = 111 Portuguese hospitals). The architecture achieves low-latency inference with privacy-by-design (local processing, no raw video storage). Stakeholder validation confirmed strong workflow fit and highlighted persistent documentation gaps during EMS-to-hospital transitions. Scenario analysis revealed distinct hardware and integration requirements (ambulance edge device versus ward multi-camera server). Bass modelling projects gradual adoption, reaching approximately 50% of Intermediate Care wards by 2037 in the realistic scenario, with the "chasm" phase occurring between 2030 and 2032. Sensitivity analysis identified early clinical evidence and FHIR integration support as the strongest accelerators of diffusion. As this constitutes a proof-of-concept study, no quantitative AVPU classification metrics (e.g., accuracy, sensitivity, specificity, or confusion matrix) are reported at this stage; empirical model evaluation against expert-annotated clinical recordings is identified as the primary prerequisite for future validation and clinical translation. As a proof-of-concept that has not yet undergone clinical validation, Consc.ia offers a feasible, interoperable solution for standardising AVPU documentation and strengthening early warning systems. By combining video analytics, edge computing, clinician validation, and FHIR integration, the platform addresses a longstanding gap in emergency-care digitalisation and provides a clear roadmap for real-world adoption.