Implementation of a nurse-initiated in-hospital stroke response system: association with early imaging and response standardization in non-specialist wards.
Ichijo M, Enatsu K, et al. • Frontiers in neurology • 2026
The MISAT nurse-initiated in-hospital stroke response system was associated with significantly shorter recognition-to-imaging time and reduced response variability, particularly in non-specialist wards, suggesting it may be 'a practical stroke-specific complement to existing emergency response systems.'
Key Findings
Results
Implementation of the MISAT system was associated with significantly shorter time from symptom recognition to brain imaging compared to a pre-implementation cohort.
Median recognition-to-imaging time was 44.0 [IQR 30.0–68.3] min post-implementation versus 72.0 [IQR 48.0–122.5] min pre-implementation.
The difference was statistically significant (p = 0.002).
The study analyzed 80 consecutive MISAT activations over October 2023–December 2025 at a single center.
A pre-implementation cohort served as the reference group for comparison.
Results
Of 80 MISAT activations for suspected in-hospital stroke, 65% were confirmed cerebrovascular events and 35% were stroke mimics.
52 of 80 activations (65.0%) were cerebrovascular events.
28 of 80 activations (35.0%) were stroke mimics.
The study was a single-center retrospective observational design.
Activations occurred across both specialist and non-specialist wards.
Results
The median time from symptom recognition to MISAT activation was 12.0 minutes, and from activation to imaging was 28.5 minutes.
Recognition-to-activation time: median 12.0 [IQR 5.0–28.0] min.
Activation-to-imaging time: median 28.5 [IQR 20.5–38.0] min.
These metrics represent the two sequential process-time components contributing to the overall recognition-to-imaging interval.
These times reflect the post-implementation period across all 80 activations.
Results
In non-specialist wards, recognition-to-activation time improved significantly across successive implementation phases and showed reduced variability.
Recognition-to-activation time decreased across phases: 54.0 [IQR 21.5–88.0] min in the earliest phase, to 8.0 [IQR 3.0–22.0] min and 10.0 [IQR 5.0–17.0] min in later phases.
The improvement across phases was statistically significant (Kruskal-Wallis p = 0.0039).
Reduced variability across phases was confirmed (Fligner-Killeen p = 0.0020).
Recognition-to-imaging time also decreased across phases with reduced variability in non-specialist wards.
These trends were interpreted as indicating 'potential educational and standardization benefits' of the system.
Background
The MISAT system is a nurse-initiated in-hospital stroke response in which stroke-specialist nurses are summoned when stroke is suspected, designed as a stroke-specific complement to existing rapid response systems.
The system is named the Musashino In-Hospital Stroke Action Team (MISAT).
Activation is initiated by nurses upon suspicion of stroke, without requiring physician initiation.
The system was evaluated specifically for its performance in non-specialist wards.
The authors characterize it as 'a practical stroke-specific complement to existing emergency response systems.'
What This Means
This research suggests that when hospitals implement a dedicated nurse-led stroke response team — where any nurse can trigger a rapid response from stroke-specialist nurses when a patient shows signs of stroke — the time from recognizing a possible stroke to getting a brain scan can be cut nearly in half. In this study, the median time from noticing symptoms to completing brain imaging dropped from 72 minutes before the system was introduced to 44 minutes afterward. Because rapid brain imaging is critical to determining whether a stroke is occurring and what type of treatment may be needed, this kind of time reduction could have meaningful consequences for patient care.
The study also found that wards not normally focused on stroke care — so-called non-specialist wards — showed particular improvement over time. Early in the program, it took over 50 minutes on average for staff in these wards to activate the stroke response team after recognizing symptoms. By later phases of the program, that dropped to around 8–10 minutes, and responses became much more consistent. This pattern suggests that repeated use of the system may help train and reinforce stroke awareness among general nursing staff, not just specialists.
This research suggests that a nurse-initiated, stroke-specific rapid response system can complement existing hospital emergency protocols, particularly in areas of a hospital where stroke expertise is not routinely present. The findings come from a single hospital and a retrospective observational design, so they reflect associations rather than proven cause and effect, and results may vary in different hospital settings.
Ichijo M, Enatsu K, Kyoya M, Chiba K, Ogishima T, Sato Y, et al.. (2026). Implementation of a nurse-initiated in-hospital stroke response system: association with early imaging and response standardization in non-specialist wards.. Frontiers in neurology. https://doi.org/10.3389/fneur.2026.1860811