Stroke Code Activation Time Audit
Stroke code activation time audit template for reviewing door-to-CT, door-to-needle, and door-to-puncture timing. Use it to spot delays, document causes, and route missed targets for quality review.
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Built for: Hospitals · Emergency Departments · Neurology And Stroke Programs · Acute Care Health Systems
Overview
This stroke code activation time audit template is built to review the time-critical steps in an acute stroke response from the moment the code is activated through imaging, thrombolysis, and endovascular therapy. It captures the timestamps and decision points that matter most in a stroke pathway: stroke code activation, last known well, NIHSS, door-to-CT, CT interpretation, door-to-needle, medication delay reasons, door-to-puncture, transfer or interventional activation, and whether the case was routed for quality review.
Use this template when you need a consistent case review tool for stroke performance improvement, especially after a missed target, a delayed treatment, or a case with unclear documentation. It is also useful for routine chart audits, stroke committee review, and comparing performance across shifts, teams, or sites. The template is designed to show where the delay occurred, who owned the next step, and whether the workflow was followed as expected.
Do not use it as a generic ED audit or a substitute for clinical decision-making. It is not meant for non-stroke neurologic complaints, and it should not be used to judge treatment appropriateness without the full chart context. If your facility does not perform thrombectomy, you can remove the endovascular section; if you do not administer thrombolytics, keep the imaging and activation sections for triage and transfer review. The value of the template is in making timing, variance, and cause visible in a repeatable format.
Standards & compliance context
- This template supports hospital stroke quality programs that commonly align with Joint Commission stroke measures and internal patient-safety review processes.
- The timing fields help document performance against stroke workflow expectations used in CMS-related quality programs and health-system quality dashboards.
- The imaging and treatment sections support documentation practices consistent with emergency care standards and hospital policies for time-sensitive stroke treatment.
- If your organization uses thrombectomy pathways, the puncture workflow section helps document coordination expected in acute stroke systems of care.
General regulatory context for orientation only — verify current requirements with counsel or the relevant agency before relying on this template for compliance.
What's inside this template
Case Identification and Stroke Code Activation
This section establishes the event timeline and confirms the stroke alert was activated with enough clinical context to judge the rest of the workflow.
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Stroke code activation time documented
Activation time is recorded in the chart or stroke log with a clear timestamp.
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Last known well time documented
Last known well or symptom onset time is documented and clinically plausible.
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Stroke code activation appropriateness
Activation criteria were met based on presenting symptoms and triage findings.
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Initial NIHSS documented
Baseline neurologic severity score is documented when applicable per local stroke workflow.
Imaging Workflow
This section measures whether the patient reached CT quickly, the scan was completed without avoidable delay, and interpretation was documented in time to support treatment decisions.
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Door-to-CT time (minutes)
Time from ED arrival to CT start or CT completion, per local metric definition.
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CT completed without avoidable delay
No preventable delay occurred in transport, scanner availability, or patient preparation.
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CT interpretation time documented
Time to radiology or stroke team interpretation is documented.
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Imaging workflow delay category
Primary reason for any imaging delay.
Thrombolytic Treatment Timing
This section shows whether thrombolysis was considered, approved, prepared, and administered within the expected treatment window and without undocumented delay.
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Door-to-needle time (minutes)
Time from ED arrival to thrombolytic administration.
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Eligibility decision documented before treatment
Contraindications, inclusion criteria, and treatment decision are documented before administration.
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Medication preparation and administration delay reason
Primary cause of any delay between decision and administration.
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Thrombolysis administered per protocol
Dose, route, and monitoring steps followed local stroke protocol.
Endovascular Therapy Timing
This section tracks the handoff and puncture pathway for thrombectomy cases so transfer delays and interventional activation gaps are visible.
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Door-to-puncture time (minutes)
Time from ED arrival to arterial puncture for endovascular therapy.
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Transfer or interventional team activation documented
Activation of the interventional team or transfer pathway is documented with timestamps.
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Delay source for puncture workflow
Primary reason for any delay to puncture.
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Pre-puncture checklist completed
Required pre-procedure checklist items were completed before puncture.
Documentation and Quality Review
This section confirms the chart contains the timestamps and variance notes needed to support auditability, trend analysis, and follow-up action.
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All key timestamps documented
Arrival, activation, CT, treatment, and puncture timestamps are complete and internally consistent.
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Variance or delay documented with cause
Any delay beyond target is explained with a specific cause and contributing factors.
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Case routed for quality review if target missed
Cases exceeding local targets are escalated to stroke quality review or committee follow-up.
How to use this template
- 1. Enter the patient and encounter identifiers, then record the stroke code activation time and last known well time from the chart.
- 2. Confirm whether the stroke code was appropriate and whether the initial NIHSS was documented before moving into workflow timing.
- 3. Record door-to-CT, CT completion, and CT interpretation times, then classify any imaging delay by the source documented in the chart.
- 4. If thrombolysis was considered or given, document door-to-needle time, the eligibility decision, the medication delay reason, and whether treatment followed protocol.
- 5. If endovascular therapy was pursued, capture door-to-puncture time, transfer or interventional activation, the puncture delay source, and pre-puncture checklist completion.
- 6. Review the variance summary, document the cause of any missed target, and route the case for quality review when required by policy.
Best practices
- Record timestamps from the source chart, not from memory or retrospective estimates.
- Use one reviewer definition for each timing interval so door-to-CT, door-to-needle, and door-to-puncture are measured the same way across cases.
- Flag any missing last known well time or NIHSS immediately, because those gaps weaken both clinical review and quality reporting.
- Separate imaging delay causes from treatment delay causes so radiology, pharmacy, and interventional bottlenecks are not conflated.
- Document the eligibility decision before thrombolysis whenever possible, especially when treatment is withheld.
- Capture the specific reason for delay in plain language, such as CT backlog, transport delay, pharmacy preparation, or team activation lag.
- Route every missed target to the same quality review path so repeat issues can be trended and corrected.
What this template typically catches
Issues teams running this template most often surface in practice:
Common use cases
Frequently asked questions
What does this stroke code activation time audit template cover?
It covers the core timestamps and decision points in a stroke response: activation time, last known well, NIHSS, imaging timing, thrombolytic timing, and endovascular therapy timing. It also captures whether delays were documented and whether the case was routed for quality review when targets were missed. This makes it useful for case-level review, not just aggregate reporting.
Who should complete this audit?
A stroke program coordinator, quality nurse, ED charge nurse, or designated reviewer usually completes it after the case. The most useful audits are built from chart review plus input from the ED, radiology, pharmacy, and interventional team when needed. If your facility has a stroke committee, this template can feed that review process.
How often should this audit be used?
Use it for every stroke code if you want continuous performance tracking, or for all cases that receive thrombolysis or thrombectomy if you are focusing on treatment workflows. Some teams also use it for targeted review of outlier cases, such as missed door-to-needle targets or delayed CT interpretation. The cadence should match your quality program and case volume.
Does this template align with regulatory or accreditation expectations?
Yes, it supports quality review practices commonly expected in hospital stroke programs and aligns well with Joint Commission stroke performance monitoring, CMS quality work, and internal patient-safety review. It does not replace your local policy or accreditation documentation, but it helps you capture the evidence needed for audit trails and corrective action. If your organization tracks stroke metrics for external reporting, this template can support that workflow.
What are the most common mistakes this audit helps catch?
Common misses include undocumented last known well time, missing NIHSS, unclear reasons for imaging delays, and treatment timestamps that do not match the chart sequence. Teams also often forget to document why thrombolysis was not given or why puncture was delayed. This template forces those gaps into view so they can be corrected.
Can this be customized for thrombolysis-only or thrombectomy-only cases?
Yes, you can trim the sections to match your workflow. For thrombolysis-only review, keep the activation, imaging, and needle timing sections and simplify the endovascular section. For thrombectomy-focused review, emphasize transfer activation, puncture timing, and pre-puncture checklist completion.
How does this compare with an ad hoc chart review?
An ad hoc review usually finds the obvious delay but misses the pattern behind it. This template standardizes the same timestamps and delay categories across cases, which makes trends easier to compare over time. It also reduces variation between reviewers, so your quality data is more consistent.
Can this template be used with EHR workflows or dashboards?
Yes, the fields map well to EHR chart review, stroke registry entry, and quality dashboards. Many teams use it alongside a spreadsheet or reporting tool to track door-to-CT, door-to-needle, and door-to-puncture performance. If you integrate it with your registry, keep the manual audit fields for delay cause and corrective action.
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