Vital Trace: Protocol-Constrained Patient-State Reasoning for Longitudinal Clinical Trajectories

Longitudinal clinical reasoning over electronic health records requires tracking evolving physiological measurements, laboratory results, and interventions across extended patient trajectories. Existing LLM-based clinical reasoning systems often rely on repeatedly serializing patient histories or exchanging unconstrained textual agent messages, leading to context drift, unstable reasoning, and growing inference cost over long horizons. We present Vital Trace, a protocol-constrained multi-agent framework for future clinical risk prediction over evolving ICU trajectories. Instead of maintaining unbounded textual histories, Vital Trace uses a compact persistent patient-state memory together with staged reasoning performed by four coordinated agents: a Router, Reasoner, Auditor, and Steward. To support temporally coherent reasoning, we introduce a manually curated Global Protocol containing physiological state-transition rules and a dynamic patient-state representation that tracks hemodynamic, respiratory, renal, metabolic, and inflammatory instability over time. We evaluate Vital Trace on MIMIC-IV and eICU using future vasopressor-support, respiratory-support, renal-support, and deterioration prediction tasks. Results show that structured protocol-constrained reasoning improves temporal consistency, communication stability, calibration, and interpretability compared with free-form multi-agent baselines while achieving strong predictive performance across long ICU trajectories.