A-G assessment

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Clinicians can perform an effective A-G assessment virtually through effective questioning, observation and listening.

An A-G assessment is 'a structured and systematic approach to physical assessment that considers a patient’s Airway, Breathing, Circulation, Disability, Exposure, Fluids, Glucose'.

An A-G assessment is a clinical tool that builds on a primary survey and can be used to assess, monitor and manage conditions. In-person, A-G assessments require clinicians to look, listen and feel. Videoconferencing allows clinicians to look and listen through video and audio cues and gather additional information through targeted questioning. This information can support a virtual A-G assessment.

Consultations and A-G assessments should only be conducted virtually when:

Escalation

If you identify an area of concern or any Yellow or Red Flags during the A-G assessment, address and escalate them immediately to avoid delays in care.

Escalation should follow your local protocols or the Clinical Emergency Response System (CERS).

Video A-G assessment considerations

Consider the below factors for achieving the goals of an A-G assessment via video.

Use A-G assessments to identify clinical deterioration or consumers at high risk of decline. When conducting a virtual assessment, clinicians must ask the consumer if they feel safe to remain at home or in their current location. If the consumer expresses concern, the clinician should stay connected and support arrangements for an in-person consultation and assessment.

Effective A-G assessments rely on clinical knowledge and experience whether held in-person or virtually. Clinicians must take a thorough medical history, consider existing conditions and ask specific and relevant questions.

Carers, parents, family and friends of the consumer can provide valuable information and support during the assessment. Ask them:

Where appropriate or needed, carers can assist the consumer to complete assessment tasks safely, e.g. repositioning the consumer, taking photos or moving the camera.

Looking at and observing the consumer is a key aspect of the assessment.

The camera, screen brightness and display settings may affect how a consumer appears. Discuss any concerns you have about the consumer's appearance with the consumer or carer, and consider requesting photos.

You may need to ask the consumer to reposition their camera to get a clear and complete view during the assessment. Keep in mind the consumer's safety and physical capability, and any impact of repositioning on posture assessment. If the consumer is unable to reposition safely, consider requesting photos or asking a carer to assist.

  • Repositioning with handheld devices: If it is safe to do so, the consumer can move their smartphone, tablet or laptop computer to reposition. Explain clearly to the consumer what you would like to focus on then provide further instructions as needed, e.g. "I would like to see your left knee," or "Can you please move your device a little further down, so I can see the bottom of your knee."
  • Repositioning with fixed devices: If it is safe to do so, the consumer can reposition themself when using a fixed device, e.g. a desktop computer or TV monitor. Explain clearly to the consumer what you would like to focus on then provide further instructions as needed, e.g. "I would like to see your left knee. Can you please stand up and take 2 steps back from the computer."

Consumers should be in a quiet and private location for their assessment. Consider how background noise and the quality or type of technology the consumer is using can impact audio, e.g. are the microphone, speaker or headphones limiting the ability to safely and effectively assess audio cues.

Ask the consumer if they have access to a device that can provide objective health data to support the assessment. Devices may also offer insight into vital sign trends.

Common devices include, but are not limited to:

  • thermometer
  • pulse oximeter
  • glucometer
  • blood pressure machine
  • scales
  • smart watches.

Ensure consumers are using the devices correctly to optimise accuracy of data.

Personal health devices may not have Therapeutic Goods Administration (TGA) approval and may not be calibrated correctly, which can affect data accuracy. Consider the health data from these devices alongside other assessment factors and clinical judgement.

Consumers can assist in A-G assessments by completing tasks as instructed by clinicians. If a task is more complex, it may require a demonstration by the clinician. Ensure you explain the task clearly, in plain language, and provide short logical steps.

For example, to assess an adult’s capillary refill, ask the consumer to place their left index finger close to the camera and then press with their right index finger firmly until the left finger turns white (blanches), which usually takes 2-5 seconds. Ask the consumer to remove the right finger and keep their left finger close to the camera.

Performing an A-G assessment

The following examples demonstrate how clinicians can assess signs and symptoms virtually by looking, listening and asking questions. Use clinical knowledge and experience to guide the A-G assessment.

Consumers with Red Flags are at high risk of deterioration and need prompt escalation in accordance with local Clinical Emergency Response System (CERS) protocols.

When performing a visual assessment you may need to ask the consumer to reposition the camera, lift or remove clothing or send photos.

Airway

Look for:

  • any causes of obstruction (e.g. vomit, secretions, foreign body, loose teeth, anaphylaxis)
  • neck, face or tongue oedema
  • increased work of breathing, including accessory muscle use
  • excessive drooling or inability to swallow saliva
  • posture (e.g. tripod position)

Listen for:

  • difficulty talking, inability to speak in sentences
  • abnormal air sounds (e.g. stridor, snoring, grunting, wheezing)
  • coughing
  • silence (ensure connection is not frozen and audio is working)

Ask:

  • Has your/their behaviour changed?
  • Assess level of consciousness (ACVPU, GCS).  If required, ask the carer to assist in a rouse to pain assessment.
  • Is your/their voice different than usual?
  • Can you show inside the mouth or tonsils on camera, or send a photo?

Escalate as per local CERS policy with Yellow or Red Flags such as:

  • decreased level of consciousness
  • stridor/wheeze/hoarse voice
  • foreign body
  • post oral surgery bleed

Breathing

Look for:

  • spontaneous breathing
  • rate of breathing or apnoea
  • shallow or deep respirations
  • increased work of breathing, including accessory muscle use, tracheal tug, nasal flaring
  • symmetrical chest wall movement
  • cyanosis
  • gasping or pursed lips
  • posture, e.g. tripod position
  • any sign of chest trauma or injury (asymmetry)

Listen for:

  • ability to speak in sentences, phrases, words or noises
  • abnormal breath sounds (e.g. wheezing, grunting)

Ask:

  • Do you/they have a cough? Is it productive or non-productive?
  • Do you/they get breathless when attending your usual activities of daily living (ADLs)?
  • Can you walk around the room for 30 seconds? Assess any shortness of breath on exertion.
  • How much is baby feeding? Are they pulling off the breast to feed?
  • Is baby sleeping more than usual?

Escalate as per local CERS policy with Yellow or Red Flags such as:

  • tachypnoea/bradypnoea
  • grunting or speaking in words only
  • accessory muscle use
  • cyanosis or pallor
  • head bobbing, tracheal tug or nasal flaring (paediatric)

Circulation

Look for:

  • central and peripheral skin colour (cyanosis, mottled, pallor)
  • peripheral oedema
  • sweating or diaphoresis
  • visible blood loss (amount, colour, mechanism)
  • signs of dehydration (dry mucus membranes, skin turgor, sunken eyes)
  • capillary refill

Listen for:

  • confusion in speech pattern
  • complaints of chest pain

Ask:

  • Does your/their skin feel dry or clammy compared to usual?
  • Assess dehydration:
    • Are you thirsty? Do you/they have a dry mouth?
    • How much have you/they been drinking? Is that usual?
    • How often have you been urinating/changing nappies?
    • When did you last pass urine? Was it dark, clear, yellow?
  • Can you move from sitting to standing? Do you feel any dizziness? Consider falls risk and whether a carer is required for safety.
  • Do you feel light headed or have blurred vision?
  • Do you have a headache?
  • Do your/their hands and feet feel hot or cold?
  • Have you noticed swelling in the lower legs? Can you show me your/their lower legs and feet?
  • Do you feel like you heart is racing or do you have any new sensations or pain in your chest?
  • Do you/they have any per vaginal (PV) bleeding?

Escalate as per local CERS policy with Yellow or Red Flags such as:

  • pallor
  • mottling
  • cold peripheries
  • decreased urine output
  • decreased fluid intake
  • uncontrolled bleed
  • significant blood loss including PV bleeding

Disability

Look for:

  • facial droop, asymmetry of smile
  • grimace, pained expressions
  • posture – hypotonic, abnormal flexion/extension, floppy
  • agitation or restlessness
  • pupil size, shape, reactions
  • neck stiffness
  • seizures
  • vagueness or sleepiness (hypoactive delirium)
  • floppy baby, poor head control, legs/arms hanging rather than bending

Listen for:

  • changes in speech, e.g. slurred, aphasia, dysphasia
  • confusion or change in behaviour including delirium
  • concerns from carers in changes of the consumer’s behaviour

Ask:

  • Assess level of consciousness (ACVPU, GCS). If required, ask the carer to assist in a rouse to pain assessment
  • Do you have any pain? Follow up with pain scale (i.e. 0-10) and assessment as clinically indicated
  • Is there any numbness or weakness in limbs?
  • Has there been any change in behaviour?
  • Have you/they had any unusual movements or signs of seizure?
  • Can you show me how you walk? Consider falls risk and whether a carer is required for safety.
  • Can you follow instructions, e.g. Can you follow my finger on screen, or turn your head?
  • Is the child's crying weak?
  • Is the child interacting with the parent as usual?

Escalate as per local CERS policy with Yellow or Red Flags such as:

  • decreased level of consciousness
  • FAST positive
  • reported overdose or ingestion of harmful substance
  • new, increasing or uncontrolled pain
  • acute or fluctuating changes in behaviour and other signs of delirium
  • inconsolable (paediatric)

Exposure

Look for:

  • bleeding, rashes, wounds, swelling, bruises
  • skin colour, e.g. well perfused, mottled, pallor, jaundice
  • signs of infection,e.g. redness, rigors
  • whether their clothing is appropriate for the temperature? Consider factors such as air conditioning.
  • distended abdomen

Listen for:

  • complaints of pain or itch

Ask:

  • Do you/they have any areas/wounds/rashes/swelling you are concerned about? Can you show me on camera or send a photo?
  • Has the wound/rash changed or spread? Outline the affected area and monitor for change in size
  • Do you feel hot or cold? Do you have a fever?
  • Have you/they had any recent falls or injuries?
  • Have you/they had prolonged exposure to heat or cold?
  • Can you/carer use a glass and apply pressure to the rash on camera to test blanching?
  • Can you show me that the abdomen is soft when you push on it?
  • Can you show me that you can jump? Consider falls risk and whether a carer is required for safety.
  • Can you show me the skin turgor? Provide instructions
  • Do you have a thermometer? If yes, what is your/their temperature?

Escalate as per local CERS policy with Yellow or Red Flags such as:

  • prolonged exposure to heat or cold
  • petechial non-blanching rash
  • painful rash
  • rigors

Fluids

Look for:

  • signs of dehydration (dry mucus membranes, skin turgor, sunken eyes)
  • signs of fluid overload, e.g. oedema
  • visible blood loss

Listen for:

  • complaints of thirst

Ask:

  • Assess dehydration:
    • Are you thirsty? Do you/they have a dry mouth?
    • How much have you/they been drinking? Is that usual?
    • How often have you been urinating/changing nappies?
    • When did you last pass urine? Was it dark, clear, yellow?
  • Have there been any urinary or bowel changes, e.g. frequency, urgency, nocturia?
  • Does the stomach feel soft or hard?
  • Have you/they had any vomiting or diarrhoea?
  • Have you noticed swelling in lower legs? Can you show me your/their lower legs and feet?

Escalate as per local CERS policy with Yellow or Red Flags such as:

  • low urine output
  • bilious vomit
  • difficulty or inability to feed or eat (paediatrics)

Glucose

Look for:

  • seizures
  • lethargy
  • sweaty and clammy skin
  • agitation

Listen for:

  • confusion
  • complaints of thirst and hunger

Ask:

  • Assess level of consciousness (ACVPU, GCS)
  • Do you/they have diabetes? How is it managed?
  • Are you/they taking any medications that could alter glucose level?
  • Assess polydipsia/thirst:
    • Are you thirsty? Is that usual?
    • How much have you/they been drinking? Is that usual?
  • Assess polyuria/urination:
    • How often/how much have you been urinating?
    • How many wet nappies have you changed today? Is that usual? (paediatric)
  • Do you feel dizzy or lightheaded?
  • Do you have a headache or blurred vision?
  • Do you feel weak or tired?
  • Do you have any nausea?
  • Do you have a glucometer? If yes what is your blood glucose level?

Escalate as per local CERS policy with Yellow or Red Flags such as:

  • decreased level of consciousness
  • seizures

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