STEMI Door-to-Balloon Time Audit

Audit template for reviewing STEMI cases to verify ECG acquisition, cath lab activation, and PCI initiation timing against door-to-balloon performance standards.

Case Identification and Timing

• Patient encounter and STEMI case identifiers documented
  Record the encounter date/time, medical record number or case ID, and location of presentation.
• Door time documented
  Document the exact time the patient arrived or was registered as the STEMI presentation time.
• First medical contact time documented when applicable
  Capture first medical contact time for EMS or transfer cases when used by the facility's STEMI workflow.
• Door-to-balloon interval calculated and recorded
  Enter the total door-to-balloon time in minutes for the case.
• Case type correctly classified
  Select the case pathway used for review.

ECG Acquisition

• Initial 12-lead ECG obtained
  Confirm that a 12-lead ECG was performed for the presenting event.
• ECG acquisition time documented
  Record the time the first ECG was obtained.
• ECG obtained within 10 minutes of arrival when indicated
  Verify the ECG met the expected rapid acquisition benchmark used in STEMI triage.
• ECG interpretation documented as STEMI or equivalent activation trigger
  Confirm the ECG interpretation supported STEMI pathway activation.
• ECG reviewed by qualified clinician
  Verify that a physician or other qualified clinician reviewed the ECG in time to support activation.

Cath Lab Activation

• Cath lab activation time documented
  Record the exact time the cath lab was activated.
• Activation occurred promptly after STEMI recognition
  Confirm activation was initiated without avoidable delay after ECG or clinical recognition.
• Activator identified
  Select who initiated the cath lab activation.
• Cath lab team notified and mobilized
  Confirm the interventional team was notified and mobilized per STEMI protocol.
• Activation delay reason documented when applicable
  Document any delay source such as diagnostic uncertainty, transfer delay, staffing, or communication failure.

PCI Initiation and Treatment

• PCI initiation time documented
  Record the time the PCI procedure began or arterial access was obtained, per local reporting definition.
• Door-to-PCI time meets performance standard
  Enter the door-to-PCI time in minutes and verify it meets the facility benchmark.
• PCI performed or transfer arranged per STEMI pathway
  Confirm the patient received PCI or was transferred appropriately for definitive reperfusion.
• Delay to PCI initiation documented when applicable
  Describe any delay between activation and PCI start, including transport, consent, access, or equipment issues.
• Reperfusion outcome recorded
  Select the treatment outcome documented in the chart.

Documentation and Quality Improvement

• All key timestamps are present and internally consistent
  Verify door time, ECG time, activation time, and PCI time are documented and logically consistent.
• Non-conformance or delay documented in chart
  Confirm any deviation from the expected STEMI pathway is documented with a clear explanation.
• Corrective action or follow-up assigned
  Document the action owner, next step, and due date for any identified delay or process gap.
• Reviewer signature
  Inspector or reviewer sign-off confirming the audit findings.