Project Summary Of the 16000 children who die every day, 7000 die because of five acute illnesses – pneumonia, diarrhea, injuries, meningitis, and malaria – largely in in low- and middle-income countries (LMICs). Appropriate and timely acute and emergency care of these children can reduce such deaths by about half. Modern emergency care systems provide care through a “chain of survival” consisting of on-scene care, emergency medical services (EMS) for transportation, and hospital emergency departments. Care and triage decisions by healthcare providers during transportation play a critical role in the eventual outcome of patients from many acute illnesses and are, therefore, considered an essential service in most high-income countries (HICs). EMS with well-trained staff, especially in the care of an acutely ill child, is rarely found in LMICs. There is a critical need – globally, but particularly in LMICs – for solutions that address the expertise/experience gap during the most critical minutes and hours of a child's transport to a fixed emergency care facility. Such solutions can contribute to potentially saving thousands of children every year. Currently, no information exists to prove the feasibility and utility of mobile health technology to guide care during transport of acutely ill children. The purpose of the study is first to assess the feasibility of implementing an ambulance-based teleconsultation (ABT) process (R21) and, if feasible, carry out a clinical trial to confirm the efficacy of the approach on the short-term clinical outcomes (R33) in Karachi, Pakistan. Our specific aims are SA1: To assess the acceptability of ABT for the emergency care of acutely ill children. SA2: To determine the feasibility of carrying out a pilot cluster-randomized trial on the impact of ABT on the Pediatric Early Warning Score (PEWS). SA3: To determine the feasibility of carrying out a cluster- randomized trial on the impact of ABT on the Pediatric Early Warning Score (PEWS). If found feasible, we will conduct an efficacy trial with the following R33 specific aims: Specific Aim 4: To test the efficacy of ABT by measuring a change in the PEWS of acutely ill children from the scene of injury/illness to the pediatric emergency department (PEM) using a cluster-randomized design Specific Aim 5: To develop the capacity of local partners in m-health research capacity.

Project Narrative Millions of children die every year, many before reaching a healthcare facility. The purpose of this two-part study is to assess the feasibility and efficacy of implementing an ambulance-based audio-video consultation process and carry out a randomized clinical trial on the efficacy of the approach on measurable clinical outcomes.