Example of signage before and after signage project at Royal North Shore Hospital (RNS)

Emergency Departments (EDs) are frequently the main point of access to hospital for many patients. They are also the only entry point to provide access to patients 24 hours a day, every day of the year.

EDs are often very busy and stressful environments for patients and carers. Anxiety and confusion may be further increased in those from culturally diverse backgrounds.

All ED signage should be prominent, concise and give clear easily identified guidance to everyone using the ED. Simple signage with plain language should be used wherever possible to avoid confusion.

Clear consistent signage will:

• Improve patient flow.
• Manage traffic flow through clinical areas.
• Improve patient, carer and staff experiences.
• Reduce confusion for patients and reduce unnecessary work for staff.
• Contribute to improved patient safety.

It is recommended, as per Hughes Walters recommendations¹ that signage is installed stating:

"If you feel unwell or wish to leave the department before treatment, please inform the nurse"

A collaborative approach to updating or designing signage is recommended to ensure it is appropriate and meets the needs of consumers, staff, the facility and the community.

All signage should be consistent with the specified guidelines at the end of this page.

 Download this page as a pdf ( 824 KB)

When designing and updating signage for ED include the following steps:

• Plan
• Involve consumers and staff
• Align with departmental objectives and legislative requirements
• Consider process and flow issues
• Use of temporary signage
• Use of electronic signage
• Evaluation

• Establish a project plan with set outcomes.
• Assign a person accountable for project outcomes e.g. ED Medical Director or Nurse Manager.
• Establish an ED 'signage' working party to:
  • Review existing signage.
  • Formulate new signage recommendations.
  • Implement new signage.
  • Review implemented signage.

A collaborative approach with patients, carers and staff will ensure that signage meets the needs of all ED users and the facility. This should include a review of signage and  recommendations. A timeline of 2-4 weeks should be adhered to in order to develop agreed recommendations.

A checklist may be used to ensure streamlined assessment of signage requirements. Download the checklist ( pdf - 39 KB).

An example of use of symbols RNS Hospital

Involving consumers and staff in the design and update of signage can help achieve a practical and usable result:

• Obtain collaborative involvement by consumers and ED staff to identify deficits and develop new signage.
• Consideration of multicultural requirements should be given throughout the signage development process.
• Involvement from those of Aboriginal or Torres Strait Islander descent, and culturally and linguistically diverse (CALD) communities should be sought, if appropriate.
• Consideration should be given from those with physical, visual, hearing, cognitive impairment and mental illness.

Internationally recognised symbols should be used to overcome language difficulties where possible. Symbols should be consistent with International Organization for Standardization (ISO) published symbols which provide universal standardised symbols as well as recommended accompanying wording for each symbol.²

Note floor signage should be durable and ensure it does not constitute a floor safety hazard. New facilities may consider incorporating signage within floor finishes.

The ED 'signage' project working party should include the following members:

• Consumer representatives (patients and carers).
• Clinical staff (e.g. medical, nursing, allied health).
• Clerical and support staff (e.g. wards person, cleaners, security).
• Health care facility representative (e.g. engineering).
• External signage consultants (e.g. signage companies can be engaged to obtain advice and quotation for local projects).

Involvement by consumers and staff will ensure deficits are identified by those who 'live' in or 'pass' through the ED environment. Diagnostic methods that have been found to be helpful include:

Photographic journal

A large sign over the triage desk may help.

Signs highlighting the security office in the waiting room would be great.

No signage to direct you to the appropriate place.

Would be good to have proper signs telling Signs on the floor may help to patients where to go direct people to the triage nurse.

An example of a photographic journal with comments written by staff members.
RNS Hospital waiting room, view on arrival.

• Interview of ED staff regarding current and potential signage.
• Review of current signage and identification of areas that require attention by a "walk through" of the ED.
• Observations within the ED to review effectiveness of signage.
• Compilation of a photographic journal. Photographs of problematic areas can be used to create a photographic book. This can be left with staff within the ED so that comments or suggestions can be entered. (See example.) It is important to keep this process brief so that a concentrated approach is made (1-2 weeks maximum).
• NSW Health Patient Survey Questionnaires ask patients the "Ease of understanding directions and signs inside and outside the hospital" and offer a 5 point scale to rate ease. This data is available for all NSW EDs via the NRC website eReports system. Data can be made available for ED Service Managers by accessing the AHS Patient Survey Contact Officer on the patient survey section of the intranet at   http://internal.health.nsw.gov.au/pubs/2008/pdf/ed_signage.pdf 
• The Statewide Patient Survey report is also available on the following NSW Health website:
  http://www.health.nsw.gov.au/hospitals/patient_survey/index.asp

Any new signage must be checked to ensure it correlates with ED operational policies and legislative requirements. Signage should be used to clearly delineate different functional areas within the ED, such as an acute treatment area or fast track zone, and ensure that access to these areas is understood by patients, carers and staff.

Signage should also correctly reflect terminology used in the ED with reference to accepted standards.³ It should be noted that it is acceptable to use the terms Triage Desk, Reception and Waiting Room in ED signage.

The importance of clear signage in the ED can not be underestimated. Signage plays a major role in the coordination of safety, process and patient flow in the ED. Inadequate or poorly placed signage may result in:

• Confusion, stress and anxiety for patients, carers and staff. This may create delays and impact poorly on experience.
• Constant interruptions to staff, as a result of patients and carers seeking directions. This may impact negatively on patient flow and workload.

Installation of adequate signage can reduce confusion, improve patient flow, patient, carer and staff experience and workload. It will also facilitate the right patient arriving in the right location on time.

Example of temporary signage RNS Hospital

The use of temporary signage, where possible, will enable the effectiveness of signage to be evaluated by consumers and staff prior to permanent installation. This can be done by repeating the steps highlighted above.

Temporary signage is also cost effective when initially updating or designing new signage in departments as it is able to be trialled prior to permanent installation.

Electronic signage is available through a number of companies and may be used to compliment existing or new signage initiatives. The benefits of electronic signage are that messages can be constantly updated as required.

Examples as per Hughes Walters¹ recommendations include:

"If you feel unwell or wish to leave the department before treatment, please inform the nurse."

It is important to evaluate the effectiveness of ED signage after update or implementation of new signage. This can be done by a "walk through" with consumers and staff to review temporary signage and by repeating the methods previously discussed.

Health care facilities, and in particular EDs are busy, complex and stressful environments. They are the one part of a hospital that require 24 hour access and therefore prominent, clear and concise signage is vital to provide guidance to everyone using the ED.

A standardised and collaborative process of review, design, implementation and evaluation is beneficial to all signage initiatives. This should include input from patients, carers, relevant community groups, staff and internal or external signage consultants.

All signage should be consistent with the following guidelines and should be referred to in conjunction with this document:

• Report of Inquiry into the Care of a Patient with Threatened Miscarriage at Royal North Shore Hospital on 25 September 2007, C.Hughes & W. Walters.
  http://www.health.nsw.gov.au/pubs/2007/inquiry_rnsh.html
• NSW Health Department (1994), Technical Series TS2 Signposting for Health Care Facilities, Sydney.
• Australian Standard AS 1428.1-2001 Design for access and mobility, Part 1: general requirements for access-New building work.
• International Organization for Standardization, ISO 7010: Graphical symbols- Safety colours and safety signs- Safety signs used in workplaces and public areas.
• The Australasian College for Emergency Medicine (ACEM), 2006, Policy on Emergency Department Signage P20, Melbourne.
• The Australasian College for Emergency Medicine (ACEM), 2007, Guidelines on Emergency Department Design G15, Melbourne.
• Department of Human Services, (2006) Emergency Signage Improvement Initiative/Emergency Departments, Final Draft. Victoria.

Emergency and Patient Flow Redesign
Health Services Performance Improvement Branch, NSW Health
Phone: 02 9391 9426

Principal Project Officer, Emergency and Patient Flow Redesign
Health Services Performance Improvement Branch, NSW Health
Phone: 02 9391 9410

1. Report of Inquiry into the Care of a Patient with Threatened Miscarriage at Royal North Shore Hospital on 25 September 2007, C.Hughes & W. Walters
   http://www.health.nsw.gov.au/pubs/2007/inquiry_rnsh.html
2. International Organization for Standardization (ISO) 7010: 18 August 2008,
   http://www.iso.org/iso/home.htm
3. Australasian College of Emergency Medicine, (2006) Policy on Emergency Department Signage P20, Melbourne.