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Today, the where can you buy amoxil over the counter U.S. Department of Health and Human Services (HHS) awarded $10.7 million from the American Rescue Plan (ARP) to expand pediatric mental health care access by integrating telehealth services into where can you buy amoxil over the counter pediatric care. The awards were made through the Health Resources and Services Administration (HRSA)."I'm proud to announce nearly $11 million in grants to expand access to pediatric mental health care through telehealth, made possible by President Biden's American Rescue Plan," said HHS Secretary Xavier Becerra.

"The buy antibiotics amoxil has where can you buy amoxil over the counter taken a toll on all of us, especially children. This critical funding will not only improve the livelihoods of children and their families, but also secure the future of our country where can you buy amoxil over the counter. We will continue to make investments that ensure our youngest Americans grow up strong and healthy." The Pediatric Mental Health Care Access Program supports state and regional networks of pediatric mental health care teams.

These teams provide tele-consultation, training, technical assistance, and care coordination for pediatric primary care and other providers to diagnose, treat, and where can you buy amoxil over the counter refer children and youth with mental health conditions and substance use disorders. The expansion announced today broadens the program's reach from 21 awards in 21 states to 45 awards in 40 states, as well as the District of Columbia, the U.S. Virgin Islands, where can you buy amoxil over the counter and the Republic of Palau.

It also provides support to two Tribal areas – the Chickasaw Nation and the Red Lake Band of the Chippewa where can you buy amoxil over the counter Indians. Currently, nearly 22 percent of children ages 3 to 17 in the United States are affected by a mental, emotional, developmental, or behavioral condition. Only about 20 percent of children with mental, emotional, or behavioral where can you buy amoxil over the counter disorders, however, receive care from a specialized provider.

"Primary care providers strive to address the many mental health challenges children and families are experiencing due to the amoxil, but they need more support," said HRSA Acting Administrator Diana Espinosa. "Expanding the Pediatric Mental Health where can you buy amoxil over the counter Care Access program offers new opportunities for providers to offer families the mental and behavioral health services they need but that often aren't easily accessible." To learn more about HRSA's Pediatric Mental Health Care Access program, visit. Https://mchb.hrsa.gov/training/pgm-pmhca.asp.

For a list of awards, visit. Https://mchb.hrsa.gov/maternal-child-health-initiatives/mental-behavioral-health/arp-pediatric-mental-health.John Nolan served in the U.S. Army and Marines and later worked in law enforcement and as a correctional officer.

A career spent dealing with traumatic events led to post-traumatic stress disorder and insomnia. He felt like his life was spinning out of control.Nolan was greatly helped by telepsychiatry services in his town, 125 miles from Little Rock, Ark. He was invited to chair the community advisory board for the largest trial of telepsychiatry to date.The five-year study, published Aug.

25 in JAMA Psychiatry, found that telepsychiatry in rural, federally qualified health centers was a resounding success for patients who had screened positive for bipolar disorder and/or PTSD.The trial was called The Study to Promote Innovation in Rural Integrated Telepsychiatry (SPIRIT). It was designed to identify the best approach to delivering tele-mental health services to rural primary-care clinics.“The results of our trial showed that if you give access to high-quality care for patients who are underserved, they improve their quality of life,” said lead researcher Dr. John Fortney, a professor of psychiatry and behavioral sciences at the University of Washington School of Medicine.The 1,004 participants were enrolled from 24 federally qualified health centers in Washington, Arkansas and Michigan.[embedded content]Without telepsychiatry, most of these patients would likely not receive help from a mental health specialist for these complex psychiatric disorders, the researchers said.In fact, only one-third of individuals with bipolar disorder and PTSD receive specialty mental health care in a year, the researchers wrote.

They said in primary care settings, only 10% of patients with these disorders receive adequate care.Nolan had originally enrolled in the study that led to this trial called Telemedicine for Outreach for PTSD at the Department of Veterans Affairs in Little Rock, also overseen by Fortney.“It made a huge difference in my life,” he said.As the SPIRIT trial wound down, Nolan said he could hear the hope and relief in the voices of participants who shared their stories in a video documentary.SPIRIT trialThe trial compared two interactive video approaches to integrate remote specialty mental health services in participating clinics. Tele-referral services involved one-on-one visits with a psychiatrist or licensed clinical psychologist. Tele-collaborative services involved a telepsychiatrist and care manager supporting visits with a primary care provider.

This collaborative model, pioneered at the UW School of Medicine, allows a psychiatrist to manage more patients than the traditional referral model.After patients completed the baseline survey, they were randomized to either get tele-referral care or tele-collaborative care.The clinics partnered with the state medical schools to provide the telepsychiatry and telepsychology services. While many federally qualified health centers provide mental health care, only about 10% of staff are psychiatrists or licensed clinical psychologists, Fortney said.By providing care from the states’ medical schools, they minimized patients’ travel burdens. And the potential stigma of a mental health care visit was averted by having the medical school providers credentialed to practice at the health center, giving the appearance of a regular healthcare visit.Results of trialPatients in both groups reported substantially and statistically significant improvements in perceived access to care, decreases in their mental health symptoms and medication side effects, and improvements in their quality of life.

There was no difference between the groups, and there were no differences in outcomes regarding age, gender, race or ethnicity.“One of the major contributions of this study is what we knew to be effective for depression and anxiety we now know also achieves good outcomes for patients with PTSD and bipolar disorder,” said Dr. Paul Pfeiffer, associate professor of psychiatry at the University of Michigan Medical School. Pfeiffer led the Michigan-based study activities.The trial results come as the buy antibiotics amoxil has enabled providers and patients alike to experience virtual care and to see the benefits for themselves, paving the way for wider adoption of telepsychiatry.Dr.

Jürgen Unützer, chair of the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine, said both the timing and impact of this trial are really important.“We're at a time now where almost everybody has sort of come to realize what a huge burden untreated mental illness and addiction problems have been,” he said.While there is still a critical workforce shortage of psychiatrists, psychologists, clinical social workers and counselors, Unützer said, this trial shows how to distribute the available workforce a little bit more effectively.This trial was funded by the Patient-Centered Outcomes Research Institute.Related. Visual abstract. Comparing interactive video approaches for treating complex psychiatric disorders.

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A Connecticut State Police sergeant who was hospitalized amoxil 250mg dosage after his vehicle was swept away by floodwaters during Storm Ida has died.The well-respected veteran trooper lost his life early Thursday morning, Sept. 2 as sweeping floodwaters in Litchfield County from the Pomperaug River flooded a road in Woodbury.Hours after Troop L last heard from him, Sergeant Brian Mohl was found by search and rescue teams in the waters of the river, swollen by the torrential rains of Ida.“It is with deep regret and sadness that I report that the State Police today lost a good man who dedicated more than a quarter-century to protecting the citizens of Connecticut," said Colonel Stavros Mellekas, Commanding Officer of the State Police. "Sgt.

Mohl was committed to helping others, to keeping public safety his priority, and to always assisting his fellow troopers."“Every line of duty death is heartbreaking and the loss of Sgt. Mohl is no different. He was outside, in the middle of the night, in horrendous conditions, patrolling the Troop L area.

He was doing a job he loved and he was taken much too soon."Mohl entered the State Police Training Academy in November 1994, and graduated on June 1995, with the 105th Training Troop. He was assigned to Troop A in Southbury and transferred to Troop L in Litchfield after being promoted to Sergeant in May 2000. He also served as Sergeant at Troop B in North Canaan, Troop G in Bridgeport, and Troop H in Hartford before returning to Troop L in 2008.He is the 25th Connecticut State Trooper to die in the line of duty.

Click here to sign up for Daily Voice's free daily emails and news alerts..

A Connecticut State Police sergeant who was where can you buy amoxil over the counter hospitalized after his vehicle was swept away by floodwaters during Storm Ida has died.The well-respected veteran trooper lost his life my response early Thursday morning, Sept. 2 as sweeping floodwaters in Litchfield County from the Pomperaug River flooded a road in Woodbury.Hours after Troop L last heard from him, Sergeant Brian Mohl was found by search and rescue teams in the waters of the river, swollen by the torrential rains of Ida.“It is with deep regret and sadness that I report that the State Police today lost a good man who dedicated more than a quarter-century to protecting the citizens of Connecticut," said Colonel Stavros Mellekas, Commanding Officer of the State Police. "Sgt. Mohl was committed to helping others, to keeping public safety his priority, and to always assisting his fellow troopers."“Every line of duty death is heartbreaking and the loss of Sgt. Mohl is no different.

He was outside, in the middle of the night, in horrendous conditions, patrolling the Troop L area. He was doing a job he loved and he was taken much too soon."Mohl entered the State Police Training Academy in November 1994, and graduated on June 1995, with the 105th Training Troop. He was assigned to Troop A in Southbury and transferred to Troop L in Litchfield after being promoted to Sergeant in May 2000. He also served as Sergeant at Troop B in North Canaan, Troop G in Bridgeport, and Troop H in Hartford before returning to Troop L in 2008.He is the 25th Connecticut State Trooper to die in the line of duty. Click here to sign up for Daily Voice's free daily emails and news alerts..

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SummaryThe 2020 Health and Independence report presents an overview of buy amoxil canada the state of public health in New Zealand, it does see here now this by presenting data from a range of sources. It complements the Ministry’s Annual Report, which includes detailed information about the strategic direction of the health and disability system and measures of its performance and impact. This report covers the period to December 2020 and includes a section on the impacts of buy antibiotics, both globally and in New Zealand.

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Looking forward – outlines the major challenges (buy antibiotics) and changes (The New Zealand Health and Disability System Review) to our national health system that will be covered in the 20201 year’s Health and Independence report.The Drug Harm Index has been corrected and republished buy amoxil canada following the identification of an error in the way some totals were calculated. Please direct any media enquiries to. [email protected]Estimates of total harm and harm per kilogram of drug consumed are included.

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SummaryThe 2020 Health where can you buy amoxil over the counter and Independence report presents an overview of the state of public health in New Zealand, it does this by presenting data from http://www.jamiegianna.com/2020/01/10/banking-on-strategy/ a range of sources. It complements the Ministry’s Annual Report, which includes detailed information about the strategic direction of the health and disability system and measures of its performance and impact. This report covers the period to December 2020 and includes a section on the impacts of buy antibiotics, both globally and in New Zealand. The 2020 report is divided into six where can you buy amoxil over the counter sections.

Starting point – presents an overview of New Zealand’s population, with an emphasis on Māori, Pacific peoples and disabled people. buy antibiotics – New Zealand had lower than expected mortality in 2020 compared with previous years, whereas globally most other countries had excess mortality. The elimination strategy used in New Zealand was successful at limiting where can you buy amoxil over the counter the numbers of cases and deaths. Health section – provides a wide range of information on various health topics.

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Looking forward – outlines the major challenges (buy antibiotics) and changes (The New Zealand Health and Disability System Review) to our national health system that will be covered in the where can you buy amoxil over the counter 20201 year’s Health and Independence report.The Drug Harm Index has been corrected and republished following the identification of an error in the way some totals were calculated. Please direct any media enquiries to. [email protected]Estimates of total harm and harm per kilogram of drug consumed are included. Illicit drugs potentially include legal drugs (such as medication) diverted to the illicit drug market and/or the misuse of medications and excludes alcohol and tobacco..

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GREAT FALLS, generic amoxil amoxicillin Mont. €” For months, the jail in central Montana’s Cascade County was free of the antibiotics, which seemed as distant a threat as it did in much of the nation’s rural Mountain West.Then a few people who had the amoxil were arrested. By the time Paul Krogue, the jail’s medical director, realized there was a problem, nearly generic amoxil amoxicillin 50 inmates were infected in the jail, where some had been sleeping on mats on an overcrowded floor.

After several weeks, Mr. Krogue got a call that s were spreading to a side of the jail that had been amoxil-free.He hung up the phone and put his head in his hands.“I just kind of lost it, like, ‘My generic amoxil amoxicillin God, I don’t know how much longer I can do this,’” Mr. Krogue, a nurse practitioner, recalled.

€œI was just scared that I’m not going to be able to see it through, that I’m going to get sick — you just feel so exhausted and it’s just a lot.”The Mountain West, which for months avoided the worst of the amoxil, has rapidly devolved into one of the most alarming hot spots in a country that recorded its eight millionth confirmed case on Thursday, a day when more than 65,000 cases were announced nationwide, the most in a single day since July.Seventeen states, including many in the Mountain West, have added more cases in the past week than any other week of the amoxil. And the spread through sparsely populated areas of rural America has created problems in small towns that lack critical resources — including doctors — even in ordinary times.Wyoming, which did generic amoxil amoxicillin not have 1,000 total cases until June, recently added more than 1,000 in a single week. Reports of new s have recently reached record levels in Alaska, Colorado and Idaho.

And Montana, where more than half of the state’s cases have been announced since August, is averaging more than 500 cases per day.In Cascade County, more than 300 inmates and staff members have been infected in a facility meant to hold 365 people, the county’s first major outbreak in a region where the amoxil is suddenly surging.The county generic amoxil amoxicillin seat, Great Falls, is seeing its worst case numbers yet. The local hospital and its 27-bed buy antibiotics unit is at capacity. The county health department is racing to hire new contact tracers.

And Mr generic amoxil amoxicillin. Krogue, who also teaches nursing at Montana State University’s Great Falls campus, has seen attendance in his classes dwindle as students fall ill or quarantine.“I was just scared that I’m not going to be able to see it through, that I’m going to get sick,” said Paul Krogue, the jail’s medical director.Credit...Tailyr Irvine for The New York TimesOne place where the s have spread has been local jails, which are confined, often crowded spaces. Jails are staples of local communities and tend to generic amoxil amoxicillin have people coming and going more quickly than prisons.

Jails can hold everyone from people awaiting criminal trials for months to those picked up for a suspended driver’s license for a few hours. With so many people filtering in and out, jails pose extra risks for the amoxil’s spread — not only inside facilities but in potentially feeding outbreaks in the rest of the community.Nationally, jails and prisons have seen disproportionate rates of and death, with a mortality rate twice as high as in the general population and an rate more than four times as high, according to recent data.A New York Times database has tracked clusters of at least 50 antibiotics cases in a dozen rural jails generic amoxil amoxicillin in Montana, Idaho, Utah and New Mexico during the amoxil. Among them.

The Purgatory Correctional Center in Hurricane, Utah, with 166 s. The jail in generic amoxil amoxicillin Twin Falls, Idaho, with 279. And, in New Mexico, the Cibola County Correctional Center, which has reported 357 cases.In Cascade County, s at the jail make up about a quarter of all known amoxil cases in the county.

Health authorities say that the jail’s outbreak, which began generic amoxil amoxicillin in mid-August, was not believed to be the main cause of the community’s recent surge, but that it had led to some cases. In the past two months, Mr. Krogue said, the jail released 29 people who were considered actively infected.s at the jail make up about a quarter of Cascade County’s known amoxil cases.Credit...Tailyr Irvine for The New York TimesGreat Falls, home to about 58,000 residents, is in the less mountainous part of Montana, with the Missouri River flowing through and a large oil refinery on its banks.

The Cascade County Detention Center sits along a highway at the edge of generic amoxil amoxicillin town. Drive five miles in any direction and you are surrounded by wide-open plains.Montana requires that masks be worn inside businesses and indoor public spaces, and many people in Great Falls wear them when walking around downtown’s Central Avenue, where shops and cafes are still recovering from shutting down in the spring. Others go generic amoxil amoxicillin without masks, citing the open space and lack of crowds.Bob Kelly, the mayor, said people had not been overly worried about how the jail outbreak might affect the rest of town when it started.“I think that by the very definition of a jail, hopefully, the disease will be incarcerated, as well as the patients,” he said.

€œIs there concern?. Sure, there’s generic amoxil amoxicillin concern. But is there overreaction?.

No.”The mayor of Great Falls said that residents had considered the jail’s outbreak a distant concern at first.Credit...Tailyr Irvine for The New York TimesSome residents’ nonchalance about the risks of the amoxil, said Mr. Krogue, the generic amoxil amoxicillin jail’s medical director, can be traced to a spring and early summer when almost no one in Cascade County knew anyone who had been sickened.“We benefited from that early on,” he said. €œBut in some ways, I think it did us a disservice, too, because it also created a certain level of complacency.”That has quickly shifted now, he said, as cases have spiked.The number of active cases known to county officials on any given day has risen sharply to about 600, according to Trisha Gardner, Cascade County’s health officer.

The county has seen 1,261 cases and six deaths during the amoxil, a generic amoxil amoxicillin Times database shows. Some of the cases have been tied to the jail outbreak, she said, and others have been connected to bars and restaurants. Even figuring out what has led to some cases has been complex, she said, as residents have been reluctant to cooperate with contact tracers.“Our hospitals are at capacity, our public health system is at capacity,” she said.

€œIt’s not sustainable at this rate.”When the outbreak at generic amoxil amoxicillin the jail began, social distancing was impossible, the authorities said. Three inmates shared cells designed for two. At night, men slept on thin blue pads in every available generic amoxil amoxicillin space.

On the floor in the day room, in shower stalls, in stairwells, in hallways outside of cells.Inmates did not receive masks until August, and jail officials said many have refused to wear them.In interviews with more than a dozen inmates and their family members, inmates described the jail during the outbreak as chaotic and unsanitary. They said their pleas for help often went unanswered by nurses and guards.Newly arriving inmates were not always quarantined from one another before their test results were known because of a lack of space, inmates and jail officials said.Owen Hawley, 30, said every inmate in his living area of 38 men had tested positive for the amoxil. He said he had been unable to eat for three days, generic amoxil amoxicillin had intensive body aches and suffered from a headache so powerful it felt as if it was “behind my eyes.”“After the fourth day of like, not eating and stuff, I just shut off, you know?.

€ he said.A jail area set aside for quarantining new inmates.Credit...Tailyr Irvine for The New York TimesAt one point, Mr. Hawley said, he and other prisoners protested the way the amoxil was being handled by refusing to leave their living generic amoxil amoxicillin areas and by blocking new inmates from entering. Everyone was ultimately tested, Mr.

Hawley said, and each prisoner was given a generic amoxil amoxicillin disposable mask.Sierra Jasmine Wells, 25, another inmate, said women in her dormitory had grown ill, one after the next.“Everyone around me was getting sick and it was tough on me,” she said. €œBy then, I had already accepted the fact that I was going to get sick.”When she became infected, she said, she was given cough syrup and Tylenol.“I kind of was just left alone to deal with it,” she said.Jesse Slaughter, the county sheriff who oversees the jail, said that the jail’s medical staff was doing everything it could, and that he had been seeking health care assistance from other counties. Officials defended their handling of the outbreak, noting that all inmates received standard medications including Tylenol twice a day and were taken to area hospitals when they needed added care.

Seven inmates, as well as some generic amoxil amoxicillin staff members, were hospitalized. No one from the jail has died from the amoxil, officials said.Sheriff Jesse Slaughter, who oversees the jail, said he had been seeking health care assistance from other counties.Credit...Tailyr Irvine for The New York TimesMr. Krogue said that since the generic amoxil amoxicillin start of the outbreak he had been working up to 16 hours each day and sleeping in his basement, away from his wife and children.

He remains healthy but says he fears bringing the amoxil home. The amoxil has slowed some in the jail, and officials have moved some inmates to other facilities, but other prisons and jails in the state are now seeing outbreaks.“You can start to see what some of these other places experienced much earlier on, and we just didn’t have that experience, but it’s certainly happening now,” Mr. Krogue said generic amoxil amoxicillin.

€œIt’s just real in a way that it wasn’t.”Lucy Tompkins reported from Great Falls, Maura Turcotte from Chicago and Libby Seline from Lincoln, Neb. Reporting was contributed by Izzy generic amoxil amoxicillin Colón from Columbia, Mo., Brendon Derr from Phoenix, Rebecca Griesbach from Tuscaloosa, Ala., Danya Issawi and Timothy Williams from New York, Ann Hinga Klein from Des Moines, K.B. Mensah from Silver Spring, Md., and Mitch Smith from Chicago.Start Preamble Federal Transit Administration (FTA), DOT.

Notice of generic amoxil amoxicillin funding opportunity. The antibiotics Disease 2019 (buy antibiotics) public health emergency Start Printed Page 63654has had a significant impact on transit operations. During a series of FTA listening sessions held over the last three months, transit agencies asked FTA to support research to identify solutions to address the operational challenges that they are facing as a result of buy antibiotics.

In response, FTA makes available through this Notice of Funding Opportunity (NOFO) funding generic amoxil amoxicillin to support research demonstration grants to public transit agencies to develop, deploy, and demonstrate innovative solutions that improve the operational efficiency of transit agencies, as well as enhance the mobility of transit users affected by the buy antibiotics public health emergency. Demonstration grants under this NOFO are authorized under FTA's Public Transportation Innovation Program (49 U.S.C. 5312).

Eligible projects will demonstrate innovative solutions to improve the operational efficiencies of transit systems and enhance mobility for their communities in four major areas. (1) Vehicle, facility, equipment and infrastructure cleaning and dis. (2) exposure mitigation measures.

(3) innovative mobility such as contactless payments. And (4) measures that strengthen public confidence in transit services. The total funding available for awards under this NOFO is $10,000,000.

FTA may supplement this amount if additional funding becomes available. Applicants must submit completed proposals for funding opportunity FTA-2020-015-TRI through the GRANTS.GOV “APPLY” function by 11:59 p.m. Eastern Time on November 2, 2020.

Prospective applicants should register as soon as possible on the GRANTS.GOV website to ensure they can complete the application process before the submission deadline. Application instructions are available on FTA's website at http://transit.dot.gov/​howtoapply and in the “FIND” module of GRANTS.GOV. FTA will not accept mail and fax submissions.

Start Further Info Please send any questions on this notice to Jamel El-Hamri email. Jamel.El-Hamri@dot.gov phone. 2020-366-8985.

A Telecommunication Device for the Deaf (TDD) is available for individuals who are deaf or hard of hearing at 1-800-877-8339. End Further Info End Preamble Start Supplemental Information Table of Contents A. Program Description B.

Federal Award Information C. Eligibility Information D. Application and Submission Information E.

Application Review Information F. Federal Award Administration Information G. Federal Awarding Agency Contact Information A.

Program Description The Public Transportation buy antibiotics Research Demonstration Grant Program is funded through the Public Transportation Innovation Program (49 U.S.C. 5312), with the goal to develop, deploy, and demonstrate innovative solutions that improve the operational efficiency of transit agencies, as well as enhance the mobility of transit users affected by the buy antibiotics public health emergency. Eligible projects will propose to develop and deploy innovative solutions in four major areas.

(1) Vehicle, facility, equipment and infrastructure cleaning and dis. (2) exposure mitigation measures. (3) innovative mobility such as contactless payments.

And (4) measures that strengthen public confidence in transit. As required by 49 U.S.C. 5312(e)(4), projects funded under this NOFO must participate in an evaluation by an independent outside entity that will conduct a comprehensive evaluation of the success or failure of the projects funded under this subsection and any plan for broad-based implementation of the innovation promoted by successful projects.

B. Federal Award Information FTA makes available $10,000,000 in fiscal year (FY) 2020 funds under the Public Transportation Innovation Program (49 U.S.C. 5312) to finance the Public Transportation buy antibiotics Research Demonstration Grant Program.

FTA may supplement the total funds available if additional funding becomes available at the time project selections are made. FTA will grant pre-award authority starting on the date of the project award announcement for selected projects and should be completed within 24 months from the date of award. Funds are available only for eligible expenses incurred after the announcement of project selections.

C. Eligibility Information (1) Eligible Applicants Eligible applicants include State and local governmental authorities, direct recipients of Urbanized Area (49 U.S.C. 5307) and Rural Area (49 U.S.C.

5311) formula funds, and Indian tribes. Eligible applicants are limited to FTA grantees or subrecipients who would be the primary beneficiaries of the innovative products and services that are developed—typically public transit agencies. Except for projects proposed by Indian tribes, proposals for projects in rural (non-urbanized) areas must be submitted as part of a consolidated State proposal.

States and other eligible applicants also may submit consolidated proposals for projects in urbanized areas. The submission of the Statewide application will not preclude the submission and consideration of any application from other eligible recipients in an urbanized area in a State. Proposals may contain projects to be implemented by the recipient or its subrecipients.

Eligible subrecipients include public agencies, private nonprofit organizations, and private providers engaged in public transportation. Eligible applicants may submit consolidated proposals for projects. (2) Cost Sharing or Matching The maximum Federal share of project costs is 100 percent.

FTA may give additional consideration to applicants that propose a local share and may view these applicants as more competitive. The applicant must document the source(s) of the local match, if any, in the grant application. For any applicants proposing match, eligible local match sources include the following.

Cash from non-Government sources other than revenues from providing public transportation services. Revenues derived from the sale of advertising and concessions. Revenues generated from value capture financing mechanisms.

Funds from an undistributed cash surplus. Replacement or depreciation cash fund or reserve. New capital.

Or in-kind contributions. (3) Eligible Projects Eligible projects will propose innovative solutions to improve operational efficiencies of transit agencies and enhance the mobility of transit users, through projects that demonstrate innovative solutions for. Vehicle, facility, equipment and infrastructure cleaning and dis.

Exposure mitigation measures such a real-time notification of rail and bus passenger loads. New multi-modal payment innovative mobility systems such as contactless payments. And measures that strengthen public confidence in transit.

Each applicant may only submit one proposal.Start Printed Page 63655 D. Application and Submission Information (1) Address and Form of Application Submission Applications must be submitted through GRANTS.GOV. Applicants can find general information for submitting applications through GRANTS.GOV at www.fta.dot.gov/​howtoapply, along with specific instructions for the forms and attachments required for submission.

Mail and fax submissions will not be accepted. (2) Content and Form of Application Submission a. Proposal Submission A complete proposal submission consists of at least two forms.

1. The SF-424 Mandatory Form (downloadable from GRANTS.GOV) and 2. The supplemental form for the FY 2020 buy antibiotics Demonstration Program (downloadable from GRANTS.GOV), which is available on FTA's website at (placeholder for FTA buy antibiotics Demonstration Program).

The application must include responses to all sections of the SF-424 mandatory form and the supplemental form unless a section is indicated as optional. FTA will use the information on the supplemental form to determine applicant and project eligibility for the program and to evaluate the proposal against the selection criteria described in part E of this notice. FTA will accept only one supplemental form per SF-424 submission.

FTA encourages applicants to consider submitting a single supplemental form that includes multiple activities to be evaluated as a consolidated proposal. Applicants may attach additional supporting information to the SF-424 submission, including but not limited to letters of support, project budgets, or excerpts from relevant planning documents. Supporting documentation must be described and referenced by file name in the appropriate response section of the supplemental form, or it may not be reviewed.

Information such as applicant name, Federal amount requested, local match amount, description of areas served, etc., may be requested in varying degrees of detail on both the SF-424 form and supplemental form. Applicants must fill in all fields unless stated otherwise on the forms. If applicants copy information into the supplemental form from another source, they should verify that the supplemental form has fully captured pasted text and that it has not truncated the text due to character limits built into the form.

Applicants should use both the “Check Package for Errors” and the “Validate Form” validation buttons on both forms to check all required fields. Applicants should also ensure that the Federal and local amounts specified are consistent. Addressing the deteriorating conditions and disproportionately high fatality rates on our rural transportation infrastructure is of critical interest to the Department, as rural transportation networks face unique challenges in safety, infrastructure condition, and passenger and freight usage.

Consistent with the R.O.U.T.E.S. Initiative, the Department encourages applicants to consider how the project will address the challenges faced by rural areas. B.

Application Content The SF-424 Mandatory Form and the supplemental form will prompt applicants for the required information, including. I. Applicant Name ii.

Dun and Bradstreet (D&B) Data Universal Numbering System (DUNS) number iii. Key contact information (contact name, address, email address, and phone number) iv. Congressional district(s) where project will take place v.

Project Information (title, executive summary, and type) vi. A detailed description of the need for the project vii. A detailed description of how the project will support the Program objectives viii.

Evidence that the applicant can provide the local cost shares ix. A description of the technical, legal, and financial capacity of the applicant x. A detailed project budget xi.

Details on the local matching funds xii. A detailed project timeline xiii. Whether the project impacts an Opportunity Zone (3) Unique Entity Identifier and System for Award Management (SAM) Each applicant is required to.

(1) Be registered in SAM before submitting an application. (2) provide a valid unique entity identifier in its application. And (3) continue to maintain an active SAM registration with current information at all times during which the applicant has an active Federal award or an application or plan under consideration by FTA.

These requirements do not apply if the applicant. (1) Is excepted from the requirements under 2 CFR 25.110(b) or (c). Or (2) has an exception approved by FTA under 2 CFR 25.110(d).

FTA may not make an award until the applicant has complied with all applicable unique entity identifier and SAM requirements. If an applicant has not fully complied with the requirements by the time FTA is ready to make an award, FTA may determine that the applicant is not qualified to receive an award and use that determination as a basis for making a Federal award to another applicant. All applicants must provide a unique entity identifier provided by SAM.

Registration in SAM may take as little as 3-5 business days, but there can be unexpected steps or delays. For example, the applicant may need to obtain an Employer Identification Number. FTA recommends allowing ample time, up to several weeks, to complete all steps.

For additional information on obtaining a unique entity identifier, please visit www.sam.gov. (4) Submission Dates and Times Project proposals must be submitted electronically through GRANTS.GOV by 11:59 p.m. Eastern on November 2, 2020.

Mail and fax submissions will not be accepted. FTA urges applicants to submit applications at least 72 hours prior to the due date to allow time to correct any problems that may have caused either GRANTS.GOV or FTA systems to reject the submission. Proposals submitted after the deadline will only be considered under extraordinary circumstances not within the applicant's control.

Deadlines will not be extended due to scheduled website maintenance. GRANTS.GOV scheduled maintenance and outage times are announced on the GRANTS.GOV website. Within 48 hours after submitting an electronic application, the applicant should receive two email messages from GRANTS.GOV.

(1) Confirmation of successful transmission to GRANTS.GOV. And (2) confirmation of successful validation by GRANTS.GOV. If the applicant does not receive confirmation of successful validation or receives a notice of failed validation or incomplete materials, the applicant must address the reason for the failed validation, as described in the email notice, and resubmit before the submission deadline.

If making a resubmission for any reason, applicants must include all original attachments regardless of which attachments were updated and check the box on the supplemental form indicating this is a resubmission. Applicants are encouraged to begin the process of registration on the GRANTS.GOV site well in advance of the submission deadline. Registration is Start Printed Page 63656a multi-step process, which may take several weeks to complete before an application can be submitted.

Registered applicants may still be required to update their registration before submitting an application. Registration in SAM is renewed annually and persons making submissions on behalf of the Authorized Organization Representative (AOR) must be authorized in GRANTS.GOV by the AOR to make submissions. (5) Funding Restrictions Funds may be used for post-award expenditures only.

Funds under this NOFO cannot be used to reimburse projects for otherwise eligible expenses incurred prior to the date of project award announcements. (6) Other Submission Requirements FTA encourages applicants to identify scaled funding options in case insufficient funding is available to fund a project at the full requested amount. If an applicant indicates that a project is scalable, the applicant must provide an appropriate minimum funding amount that will fund an eligible project that achieves the objectives of the program and meets all relevant program requirements.

The applicant must provide a clear explanation of how a reduced award would affect the project budget and scope. FTA may award a lesser amount whether or not the applicant provides a scalable option. E.

Application Review Information (1) Project Evaluation Criteria Addressing the deteriorating conditions and disproportionately high fatality rates on our rural transportation infrastructure is of critical interest to the Department, as rural transportation networks face unique challenges in safety, infrastructure condition, and passenger and freight usage. Consistent with the R.O.U.T.E.S. Initiative, the Department will consider how the project will address the challenges faced by rural areas.

In addition, the Department will review and consider applications for funding pursuant to this Notice in accordance with the President's September 2, 2020 memorandum, entitled Memorandum on Reviewing Funding to State and Local Government Recipients of Federal Funds that Are Permitting Anarchy, Violence, and Destruction in American Cities, consistent with guidance from the Office of Management and Budget and the Attorney General and with all applicable laws. FTA will evaluate proposals submitted according to the following criteria. (a) Project Innovation and Impact.

(b) Project Approach. (c) National Applicability. (d) Commercialization and/or Knowledge Transfer.

And (e) Technical, Legal and Financial Capacity. FTA encourages each applicant to demonstrate how a project supports all criteria with the most relevant information the applicant can provide, regardless of whether such information has been specifically requested or identified in this notice. A.

Project Innovation and Impact i. Effectiveness of the project in achieving and demonstrating the specific objectives of this program. Ii.

Demonstration of benefits in addressing the needs of the transit agency and industry and impacts to infrastructure, equipment, transit workforce, and riders. Iii. Degree of improvement over current and existing technologies, designs, and/or practices applicable to the transit industry.

B. Project Approach i. Quality of the project approach such as existing partnerships, collaboration strategies and level of commitment of the project partners.

Ii. Proposal is realistic in its approach to fulfill the milestones/deliverables, schedule and goals. C.

National Applicability i. Degree to which the project could be replicated by other transit agencies regionally or nationally. Ii.

Ability to evaluate technologies, designs and/or practices in a wide variety of conditions and locales. Iii. Degree to which the technology, designs and/or practices can be replicated by other transportation modes.

D. Commercialization and/or Knowledge Transfer i. Demonstrates a realistic plan for moving the results of the project into the transit marketplace (patents, conferences, articles in trade magazines, webinar, site visits, etc.).

Ii. How the project team plans to work with the industry on improving best practices, guidance and/or standards, if applicable. Iii.

Demonstrate a clear understanding and robust approach to data collection, access and management. E. Technical, Legal and Financial Capacity Capacity of the applicant and any partners to successfully execute the project effort.

There should be no outstanding legal, technical, or financial issues with the applicant that would make this a high-risk project. (2) Review and Selection Process An FTA technical evaluation committee will evaluate proposals based on the published project evaluation criteria. Members of the technical evaluation committee will rate the applications and may seek clarification about any statement in an application.

The FTA Administrator will determine the final selection and amount of funding for each project after consideration of the findings of the technical evaluation committee. Geographic diversity, diversity of the project type, the amount of local match to be provided, and the applicant's receipt and management of other Federal transit funds may be considered in FTA's award decisions. Prior fare payment innovation efforts may receive priority consideration.

The FTA Administrator will consider the following key DOT objectives. A. Utilizing alternative funding sources and innovative financing models to attract non-Federal sources of investment.

B. Whether the project is located in or supports public transportation service in a qualified opportunity zone designated pursuant to 26.U.S.C. 1400Z-1.

And c. The extent to which the project addresses challenges specific to the provision of rural public transportation. (3) FAPIIS Review Prior to making a grant award, FTA is required to review and consider any information about the applicant that is in the Federal Awardee Performance and Integrity Information System (FAPIIS) accessible through SAM.

An applicant may review and comment on information about itself that a Federal awarding agency previously entered. FTA will consider any comments by the applicant, in addition to the other information in FAPIIS, in making a judgment about the applicant's integrity, business ethics, and record of performance under Federal awards when completing the review of risk posed by applicants as described in 2 CFR 200.205 Federal Awarding Agency Review of Risk Posed by Applicants. F.

Federal Award Administration Information (1) Federal Award Notices FTA will announce the final project selections on the FTA website. Project recipients should contact their FTA Regional Office for additional information regarding allocations for Start Printed Page 63657projects. At the time project selections are announced, FTA will extend pre-award authority for the selected projects.

There is no blanket pre-award authority for these projects before announcement. There is no minimum or maximum grant award amount, but FTA intends to fund as many meritorious projects as possible. FTA only will consider proposals from eligible recipients for eligible activities.

Due to funding limitations, projects selected for funding may receive less than the amount originally requested. In those cases, applicants must be able to demonstrate that the proposed projects are still viable and can be completed with the amount awarded. (2) Administrative and National Policy Requirements a.

Pre-Award Authority FTA will issue specific guidance to recipients regarding pre-award authority at the time of selection. FTA does not provide pre-award authority for competitive funds until projects are selected, and there are Federal requirements that must be met before costs are incurred. For more information about FTA's policy on pre-award authority, see the FY 2020 Apportionments Notice published on June 3, 2020, at https://www.govinfo.gov/​content/​pkg/​FR-2020-06-03/​pdf/​2020-11946.pdf.

b. Grant Requirements Selected applicants will submit a grant application through FTA's electronic grant management system and adhere to the customary FTA grant requirements for research project (insert Circular name). All competitive grants, regardless of award amount, will be subject to the Congressional notification and release process.

FTA emphasizes that third-party procurement applies to all funding awards, as described in FTA Circular 4220.1F, “Third Party Contracting Guidance.” However, FTA may approve applications that include a specifically identified partnering organization(s) (2 CFR 200.302(f)). When included, the application, budget, and budget narrative should provide a clear understanding of how the selection of these organizations is critical for the project and give sufficient detail about the costs involved. C.

Planning FTA encourages applicants to engage the appropriate State Departments of Transportation, Regional Transportation Planning Organizations, or Metropolitan Planning Organizations in areas to be served by the project funds available under this program. D. Standard Assurances The applicant assures that it will comply with all applicable Federal statutes, regulations, executive orders, FTA circulars, and other Federal administrative requirements in carrying out any project supported by the FTA grant.

The applicant acknowledges that it is under a continuing obligation to comply with the terms and conditions of the grant agreement issued for its project with FTA. The applicant understands that Federal laws, regulations, policies, and administrative practices might be modified from time to time and may affect the implementation of the project. The applicant agrees that the most recent Federal requirements will apply to the project unless FTA issues a written determination otherwise.

The applicant must submit the Certifications and Assurances before receiving a grant if it does not have current certifications on file. E. Free Speech and Religious Liberty In connection with any program or activity conducted with or benefiting from funds awarded under this notice, recipients of funds must comply with all applicable requirements of Federal law, including, without limitation, the Constitution of the United States.

Statutory, regulatory, and public policy requirements, including without limitation, those protecting free speech, religious liberty, public welfare, the environment, and prohibiting discrimination. The conditions of performance, non-discrimination requirements, and other assurances made applicable to the award of funds in accordance with regulations of the Department of Transportation. And applicable Federal financial assistance and contracting principles promulgated by the Office of Management and Budget.

In complying with these requirements, recipients must ensure that no concession agreements are denied or other contracting decisions made on the basis of speech or other activities protected by the First Amendment. If the Department determines that a recipient has failed to comply with applicable Federal requirements, the Department may terminate the award of funds and disallow previously incurred costs, requiring the recipient to reimburse any expended award funds. (3) Reporting The post-award reporting requirements include submission of the Federal Financial Report (FFR) and Milestone Progress Report in TrAMS.

An evaluation of the grant will occur at various points in the demonstration process and at the end of the project. In addition, FTA is responsible for producing an Annual Report to Congress that compiles evaluation of selected projects, including an evaluation of the performance measures identified by the applicants. All applicants must develop an evaluation plan to measure the success or failure of their projects and describe any plans for broad-based implementation of successful projects.

FTA may request data and reports to support the evaluation and Annual Report. A. Independent Evaluation To achieve a comprehensive understanding of the impacts and implications of each proposed buy antibiotics Research Demonstration Program, projects funded under this announcement will require the recipient to conduct a third party independent evaluation of their project.

Recipients will be required to contract with a third party independent evaluator to assist in developing an evaluation plan, and collecting, storing and managing data required to fulfill the evaluation requirement. No more than 10 percent of the Federal share of the project may be used to hire the third-party independent evaluator and the inclusion of a third-party independent evaluation should be described in the grant application. If the project duration is more than two years, an interim evaluation report would need to be submitted to FTA, otherwise the evaluation report should be included as part of the final project report.

B. buy antibiotics Research Demonstration Grant Program Evaluation Projects funded under this announcement will be required to establish a set of performance metrics set by the third-party independent evaluator and shared with FTA. G.

Federal Awarding Agency Contacts Information For questions about applying, please contact Jamel El-Hamri email. Jamel.El-Hamri@dot.gov phone. 202-366-8985.

A TDD is available at 1-800-877-8339 (TDDFIRS). To ensure that applicants receive accurate information about eligibility or the program, applicants are encouraged to contact FTA directly with questions, rather than through intermediaries or third parties.Start Printed Page 63658 FTA staff also may conduct briefings on the competitive grants selection and award process upon request. Start Signature K.

Jane Williams, Deputy Administrator. End Signature End Supplemental Information [FR Doc. 2020-22316 Filed 10-7-20.

GREAT FALLS, where can you buy amoxil over the counter this contact form Mont. €” For months, the jail in central Montana’s Cascade County was free of the antibiotics, which seemed as distant a threat as it did in much of the nation’s rural Mountain West.Then a few people who had the amoxil were arrested. By the time Paul Krogue, the jail’s medical director, realized there was a problem, where can you buy amoxil over the counter nearly 50 inmates were infected in the jail, where some had been sleeping on mats on an overcrowded floor. After several weeks, Mr. Krogue got where can you buy amoxil over the counter a call that s were spreading to a side of the jail that had been amoxil-free.He hung up the phone and put his head in his hands.“I just kind of lost it, like, ‘My God, I don’t know how much longer I can do this,’” Mr.

Krogue, a nurse practitioner, recalled. €œI was just scared that I’m not going to be able to see it through, that I’m going to get sick — you just feel so exhausted and it’s just a lot.”The Mountain West, which for months avoided the worst of the amoxil, has rapidly devolved into one of the most alarming hot spots in a country that recorded its eight millionth confirmed case on Thursday, a day when more than 65,000 cases were announced nationwide, the most in a single day since July.Seventeen states, including many in the Mountain West, have added more cases in the past week than any other week of the amoxil. And the spread through sparsely populated areas of rural America has created problems in small towns that lack critical resources — including doctors — even in ordinary times.Wyoming, which did not have 1,000 total cases until June, recently added more where can you buy amoxil over the counter than 1,000 in a single week. Reports of new s have recently reached record levels in Alaska, Colorado and Idaho. And Montana, where more than half of the state’s cases have been announced since August, is averaging more than 500 cases per day.In Cascade County, more than 300 inmates and staff members have been infected in a facility meant to hold 365 people, the county’s first major outbreak in a region where the amoxil is suddenly surging.The county seat, Great Falls, is seeing its worst case numbers yet where can you buy amoxil over the counter.

The local hospital and its 27-bed buy antibiotics unit is at capacity. The county health department is racing to hire new contact tracers. And Mr where can you buy amoxil over the counter. Krogue, who also teaches nursing at Montana State University’s Great Falls campus, has seen attendance in his classes dwindle as students fall ill or quarantine.“I was just scared that I’m not going to be able to see it through, that I’m going to get sick,” said Paul Krogue, the jail’s medical director.Credit...Tailyr Irvine for The New York TimesOne place where the s have spread has been local jails, which are confined, often crowded spaces. Jails are staples of local communities and tend to have people coming where can you buy amoxil over the counter and going more quickly than prisons.

Jails can hold everyone from people awaiting criminal trials for months to those picked up for a suspended driver’s license for a few hours. With so many people filtering in and out, jails pose extra risks for the amoxil’s spread — not only inside facilities but in potentially feeding outbreaks in the rest of the community.Nationally, jails and prisons have seen disproportionate rates of and death, with a mortality rate twice as high as in the general population and an rate more than four where can you buy amoxil over the counter times as high, according to recent data.A New York Times database has tracked clusters of at least 50 antibiotics cases in a dozen rural jails in Montana, Idaho, Utah and New Mexico during the amoxil. Among them. The Purgatory Correctional Center in Hurricane, Utah, with 166 s. The jail in Twin Falls, Idaho, with where can you buy amoxil over the counter 279.

And, in New Mexico, the Cibola County Correctional Center, which has reported 357 cases.In Cascade County, s at the jail make up about a quarter of all known amoxil cases in the county. Health authorities say that the jail’s outbreak, which began in mid-August, was not believed to be the main cause of the community’s recent surge, but that it had led to where can you buy amoxil over the counter some cases. In the past two months, Mr. Krogue said, the jail released 29 people who were considered actively infected.s at the jail make up about a quarter of Cascade County’s known amoxil cases.Credit...Tailyr Irvine for The New York TimesGreat Falls, home to about 58,000 residents, is in the less mountainous part of Montana, with the Missouri River flowing through and a large oil refinery on its banks. The Cascade County Detention Center where can you buy amoxil over the counter sits along a highway at the edge of town.

Drive five miles in any direction and you are surrounded by wide-open plains.Montana requires that masks be worn inside businesses and indoor public spaces, and many people in Great Falls wear them when walking around downtown’s Central Avenue, where shops and cafes are still recovering from shutting down in the spring. Others go without masks, citing the open space and lack of crowds.Bob Kelly, the mayor, said people had not been overly worried about how the jail outbreak might affect the rest of town where can you buy amoxil over the counter when it started.“I think that by the very definition of a jail, hopefully, the disease will be incarcerated, as well as the patients,” he said. €œIs there concern?. Sure, there’s concern where can you buy amoxil over the counter. But is there overreaction?.

No.”The mayor of Great Falls said that residents had considered the jail’s outbreak a distant concern at first.Credit...Tailyr Irvine for The New York TimesSome residents’ nonchalance about the risks of the amoxil, said Mr. Krogue, the jail’s medical director, can be traced to a spring and early summer when almost no one in Cascade County where can you buy amoxil over the counter knew anyone who had been sickened.“We benefited from that early on,” he said. €œBut in some ways, I think it did us a disservice, too, because it also created a certain level of complacency.”That has quickly shifted now, he said, as cases have spiked.The number of active cases known to county officials on any given day has risen sharply to about 600, according to Trisha Gardner, Cascade County’s health officer. The county has seen 1,261 cases and six where can you buy amoxil over the counter deaths during the amoxil, a Times database shows. Some of the cases have been tied to the jail outbreak, she said, and others have been connected to bars and restaurants.

Even figuring out what has led to some cases has been complex, she said, as residents have been reluctant to cooperate with contact tracers.“Our hospitals are at capacity, our public health system is at capacity,” she said. €œIt’s not sustainable at this rate.”When the outbreak at the jail where can you buy amoxil over the counter began, social distancing was impossible, the authorities said. Three inmates shared cells designed for two. At night, men slept on thin blue pads in every available space where can you buy amoxil over the counter. On the floor in the day room, in shower stalls, in stairwells, in hallways outside of cells.Inmates did not receive masks until August, and jail officials said many have refused to wear them.In interviews with more than a dozen inmates and their family members, inmates described the jail during the outbreak as chaotic and unsanitary.

They said their pleas for help often went unanswered by nurses and guards.Newly arriving inmates were not always quarantined from one another before their test results were known because of a lack of space, inmates and jail officials said.Owen Hawley, 30, said every inmate in his living area of 38 men had tested positive for the amoxil. He said he had been unable to eat for three days, had intensive body aches and suffered from a where can you buy amoxil over the counter headache so powerful it felt as if it was “behind my eyes.”“After the fourth day of like, not eating and stuff, I just shut off, you know?. € he said.A jail area set aside for quarantining new inmates.Credit...Tailyr Irvine for The New York TimesAt one point, Mr. Hawley said, he and other prisoners protested where can you buy amoxil over the counter the way the amoxil was being handled by refusing to leave their living areas and by blocking new inmates from entering. Everyone was ultimately tested, Mr.

Hawley said, and each prisoner was where can you buy amoxil over the counter given a disposable mask.Sierra Jasmine Wells, 25, another inmate, said women in her dormitory had grown ill, one after the next.“Everyone around me was getting sick and it was tough on me,” she said. €œBy then, I had already accepted the fact that I was going to get sick.”When she became infected, she said, she was given cough syrup and Tylenol.“I kind of was just left alone to deal with it,” she said.Jesse Slaughter, the county sheriff who oversees the jail, said that the jail’s medical staff was doing everything it could, and that he had been seeking health care assistance from other counties. Officials defended their handling of the outbreak, noting that all inmates received standard medications including Tylenol twice a day and were taken to area hospitals when they needed added care. Seven inmates, as where can you buy amoxil over the counter well as some staff members, were hospitalized. No one from the jail has died from the amoxil, officials said.Sheriff Jesse Slaughter, who oversees the jail, said he had been seeking health care assistance from other counties.Credit...Tailyr Irvine for The New York TimesMr.

Krogue said that since where can you buy amoxil over the counter the start of the outbreak he had been working up to 16 hours each day and sleeping in his basement, away from his wife and children. He remains healthy but says he fears bringing the amoxil home. The amoxil has slowed some in the jail, and officials have moved some inmates to other facilities, but other prisons and jails in the state are now seeing outbreaks.“You can start to see what some of these other places experienced much earlier on, and we just didn’t have that experience, but it’s certainly happening now,” Mr. Krogue said where can you buy amoxil over the counter. €œIt’s just real in a way that it wasn’t.”Lucy Tompkins reported from Great Falls, Maura Turcotte from Chicago and Libby Seline from Lincoln, Neb.

Reporting was contributed by Izzy Colón from Columbia, Mo., Brendon Derr from Phoenix, Rebecca where can you buy amoxil over the counter Griesbach from Tuscaloosa, Ala., Danya Issawi and Timothy Williams from New York, Ann Hinga Klein from Des Moines, K.B. Mensah from Silver Spring, Md., and Mitch Smith from Chicago.Start Preamble Federal Transit Administration (FTA), DOT. Notice of funding opportunity where can you buy amoxil over the counter. The antibiotics Disease 2019 (buy antibiotics) public health emergency Start Printed Page 63654has had a significant impact on transit operations. During a series of FTA listening sessions held over the last three months, transit agencies asked FTA to support research to identify solutions to address the operational challenges that they are facing as a result of buy antibiotics.

In response, FTA makes available through this Notice of Funding Opportunity (NOFO) funding to support research demonstration grants to public transit agencies to develop, deploy, and demonstrate innovative solutions that improve the operational efficiency of transit agencies, as well as enhance the mobility of transit users affected by the buy antibiotics where can you buy amoxil over the counter public health emergency. Demonstration grants under this NOFO are authorized under FTA's Public Transportation Innovation Program (49 U.S.C. 5312). Eligible projects will demonstrate innovative solutions to improve the operational efficiencies of transit systems and enhance mobility for their communities in four major areas. (1) Vehicle, facility, equipment and infrastructure cleaning and dis.

(2) exposure mitigation measures. (3) innovative mobility such as contactless payments. And (4) measures that strengthen public confidence in transit services. The total funding available for awards under this NOFO is $10,000,000. FTA may supplement this amount if additional funding becomes available.

Applicants must submit completed proposals for funding opportunity FTA-2020-015-TRI through the GRANTS.GOV “APPLY” function by 11:59 p.m. Eastern Time on November 2, 2020. Prospective applicants should register as soon as possible on the GRANTS.GOV website to ensure they can complete the application process before the submission deadline. Application instructions are available on FTA's website at http://transit.dot.gov/​howtoapply and in the “FIND” module of GRANTS.GOV. FTA will not accept mail and fax submissions.

Start Further Info Please send any questions on this notice to Jamel El-Hamri email. Jamel.El-Hamri@dot.gov phone. 2020-366-8985. A Telecommunication Device for the Deaf (TDD) is available for individuals who are deaf or hard of hearing at 1-800-877-8339. End Further Info End Preamble Start Supplemental Information Table of Contents A.

Program Description B. Federal Award Information C. Eligibility Information D. Application and Submission Information E. Application Review Information F.

Federal Award Administration Information G. Federal Awarding Agency Contact Information A. Program Description The Public Transportation buy antibiotics Research Demonstration Grant Program is funded through the Public Transportation Innovation Program (49 U.S.C. 5312), with the goal to develop, deploy, and demonstrate innovative solutions that improve the operational efficiency of transit agencies, as well as enhance the mobility of transit users affected by the buy antibiotics public health emergency. Eligible projects will propose to develop and deploy innovative solutions in four major areas.

(1) Vehicle, facility, equipment and infrastructure cleaning and dis. (2) exposure mitigation measures. (3) innovative mobility such as contactless payments. And (4) measures that strengthen public confidence in transit. As required by 49 U.S.C.

5312(e)(4), projects funded under this NOFO must participate in an evaluation by an independent outside entity that will conduct a comprehensive evaluation of the success or failure of the projects funded under this subsection and any plan for broad-based implementation of the innovation promoted by successful projects. B. Federal Award Information FTA makes available $10,000,000 in fiscal year (FY) 2020 funds under the Public Transportation Innovation Program (49 U.S.C. 5312) to finance the Public Transportation buy antibiotics Research Demonstration Grant Program. FTA may supplement the total funds available if additional funding becomes available at the time project selections are made.

FTA will grant pre-award authority starting on the date of the project award announcement for selected projects and should be completed within 24 months from the date of award. Funds are available only for eligible expenses incurred after the announcement of project selections. C. Eligibility Information (1) Eligible Applicants Eligible applicants include State and local governmental authorities, direct recipients of Urbanized Area (49 U.S.C. 5307) and Rural Area (49 U.S.C.

5311) formula funds, and Indian tribes. Eligible applicants are limited to FTA grantees or subrecipients who would be the primary beneficiaries of the innovative products and services that are developed—typically public transit agencies. Except for projects proposed by Indian tribes, proposals for projects in rural (non-urbanized) areas must be submitted as part of a consolidated State proposal. States and other eligible applicants also may submit consolidated proposals for projects in urbanized areas. The submission of the Statewide application will not preclude the submission and consideration of any application from other eligible recipients in an urbanized area in a State.

Proposals may contain projects to be implemented by the recipient or its subrecipients. Eligible subrecipients include public agencies, private nonprofit organizations, and private providers engaged in public transportation. Eligible applicants may submit consolidated proposals for projects. (2) Cost Sharing or Matching The maximum Federal share of project costs is 100 percent. FTA may give additional consideration to applicants that propose a local share and may view these applicants as more competitive.

The applicant must document the source(s) of the local match, if any, in the grant application. For any applicants proposing match, eligible local match sources include the following. Cash from non-Government sources other than revenues from providing public transportation services. Revenues derived from the sale of advertising and concessions. Revenues generated from value capture financing mechanisms.

Funds from an undistributed cash surplus. Replacement or depreciation cash fund or reserve. New capital. Or in-kind contributions. (3) Eligible Projects Eligible projects will propose innovative solutions to improve operational efficiencies of transit agencies and enhance the mobility of transit users, through projects that demonstrate innovative solutions for.

Vehicle, facility, equipment and infrastructure cleaning and dis. Exposure mitigation measures such a real-time notification of rail and bus passenger loads. New multi-modal payment innovative mobility systems such as contactless payments. And measures that strengthen public confidence in transit. Each applicant may only submit one proposal.Start Printed Page 63655 D.

Application and Submission Information (1) Address and Form of Application Submission Applications must be submitted through GRANTS.GOV. Applicants can find general information for submitting applications through GRANTS.GOV at www.fta.dot.gov/​howtoapply, along with specific instructions for the forms and attachments required for submission. Mail and fax submissions will not be accepted. (2) Content and Form of Application Submission a. Proposal Submission A complete proposal submission consists of at least two forms.

1. The SF-424 Mandatory Form (downloadable from GRANTS.GOV) and 2. The supplemental form for the FY 2020 buy antibiotics Demonstration Program (downloadable from GRANTS.GOV), which is available on FTA's website at (placeholder for FTA buy antibiotics Demonstration Program). The application must include responses to all sections of the SF-424 mandatory form and the supplemental form unless a section is indicated as optional. FTA will use the information on the supplemental form to determine applicant and project eligibility for the program and to evaluate the proposal against the selection criteria described in part E of this notice.

FTA will accept only one supplemental form per SF-424 submission. FTA encourages applicants to consider submitting a single supplemental form that includes multiple activities to be evaluated as a consolidated proposal. Applicants may attach additional supporting information to the SF-424 submission, including but not limited to letters of support, project budgets, or excerpts from relevant planning documents. Supporting documentation must be described and referenced by file name in the appropriate response section of the supplemental form, or it may not be reviewed. Information such as applicant name, Federal amount requested, local match amount, description of areas served, etc., may be requested in varying degrees of detail on both the SF-424 form and supplemental form.

Applicants must fill in all fields unless stated otherwise on the forms. If applicants copy information into the supplemental form from another source, they should verify that the supplemental form has fully captured pasted text and that it has not truncated the text due to character limits built into the form. Applicants should use both the “Check Package for Errors” and the “Validate Form” validation buttons on both forms to check all required fields. Applicants should also ensure that the Federal and local amounts specified are consistent. Addressing the deteriorating conditions and disproportionately high fatality rates on our rural transportation infrastructure is of critical interest to the Department, as rural transportation networks face unique challenges in safety, infrastructure condition, and passenger and freight usage.

Consistent with the R.O.U.T.E.S. Initiative, the Department encourages applicants to consider how the project will address the challenges faced by rural areas. B. Application Content The SF-424 Mandatory Form and the supplemental form will prompt applicants for the required information, including. I.

Applicant Name ii. Dun and Bradstreet (D&B) Data Universal Numbering System (DUNS) number iii. Key contact information (contact name, address, email address, and phone number) iv. Congressional district(s) click this site where project will take place v. Project Information (title, executive summary, and type) vi.

A detailed description of the need for the project vii. A detailed description of how the project will support the Program objectives viii. Evidence that the applicant can provide the local cost shares ix. A description of the technical, legal, and financial capacity of the applicant x. A detailed project budget xi.

Details on the local matching funds xii. A detailed project timeline xiii. Whether the project impacts an Opportunity Zone (3) Unique Entity Identifier and System for Award Management (SAM) Each applicant is required to. (1) Be registered in SAM before submitting an application. (2) provide a valid unique entity identifier in its application.

And (3) continue to maintain an active SAM registration with current information at all times during which the applicant has an active Federal award or an application or plan under consideration by FTA. These requirements do not apply if the applicant. (1) Is excepted from the requirements under 2 CFR 25.110(b) or (c). Or (2) has an exception approved by FTA under 2 CFR 25.110(d). FTA may not make an award until the applicant has complied with all applicable unique entity identifier and SAM requirements.

If an applicant has not fully complied with the requirements by the time FTA is ready to make an award, FTA may determine that the applicant is not qualified to receive an award and use that determination as a basis for making a Federal award to another applicant. All applicants must provide a unique entity identifier provided by SAM. Registration in SAM may take as little as 3-5 business days, but there can be unexpected steps or delays. For example, the applicant may need to obtain an Employer Identification Number. FTA recommends allowing ample time, up to several weeks, to complete all steps.

For additional information on obtaining a unique entity identifier, please visit www.sam.gov. (4) Submission Dates and Times Project proposals must be submitted electronically through GRANTS.GOV by 11:59 p.m. Eastern on November 2, 2020. Mail and fax submissions will not be accepted. FTA urges applicants to submit applications at least 72 hours prior to the due date to allow time to correct any problems that may have caused either GRANTS.GOV or FTA systems to reject the submission.

Proposals submitted after the deadline will only be considered under extraordinary circumstances not within the applicant's control. Deadlines will not be extended due to scheduled website maintenance. GRANTS.GOV scheduled maintenance and outage times are announced on the GRANTS.GOV website. Within 48 hours after submitting an electronic application, the applicant should receive two email messages from GRANTS.GOV. (1) Confirmation of successful transmission to GRANTS.GOV.

And (2) confirmation of successful validation by GRANTS.GOV. If the applicant does not receive confirmation of successful validation or receives a notice of failed validation or incomplete materials, the applicant must address the reason for the failed validation, as described in the email notice, and resubmit before the submission deadline. If making a resubmission for any reason, applicants must include all original attachments regardless of which attachments were updated and check the box on the supplemental form indicating this is a resubmission. Applicants are encouraged to begin the process of registration on the GRANTS.GOV site well in advance of the submission deadline. Registration is Start Printed Page 63656a multi-step process, which may take several weeks to complete before an application can be submitted.

Registered applicants may still be required to update their registration before submitting an application. Registration in SAM is renewed annually and persons making submissions on behalf of the Authorized Organization Representative (AOR) must be authorized in GRANTS.GOV by the AOR to make submissions. (5) Funding Restrictions Funds may be used for post-award expenditures only. Funds under this NOFO cannot be used to reimburse projects for otherwise eligible expenses incurred prior to the date of project award announcements. (6) Other Submission Requirements FTA encourages applicants to identify scaled funding options in case insufficient funding is available to fund a project at the full requested amount.

If an applicant indicates that a project is scalable, the applicant must provide an appropriate minimum funding amount that will fund an eligible project that achieves the objectives of the program and meets all relevant program requirements. The applicant must provide a clear explanation of how a reduced award would affect the project budget and scope. FTA may award a lesser amount whether or not the applicant provides a scalable option. E. Application Review Information (1) Project Evaluation Criteria Addressing the deteriorating conditions and disproportionately high fatality rates on our rural transportation infrastructure is of critical interest to the Department, as rural transportation networks face unique challenges in safety, infrastructure condition, and passenger and freight usage.

Consistent with the R.O.U.T.E.S. Initiative, the Department will consider how the project will address the challenges faced by rural areas. In addition, the Department will review and consider applications for funding pursuant to this Notice in accordance with the President's September 2, 2020 memorandum, entitled Memorandum on Reviewing Funding to State and Local Government Recipients of Federal Funds that Are Permitting Anarchy, Violence, and Destruction in American Cities, consistent with guidance from the Office of Management and Budget and the Attorney General and with all applicable laws. FTA will evaluate proposals submitted according to the following criteria. (a) Project Innovation and Impact.

(b) Project Approach. (c) National Applicability. (d) Commercialization and/or Knowledge Transfer. And (e) Technical, Legal and Financial Capacity. FTA encourages each applicant to demonstrate how a project supports all criteria with the most relevant information the applicant can provide, regardless of whether such information has been specifically requested or identified in this notice.

A. Project Innovation and Impact i. Effectiveness of the project in achieving and demonstrating the specific objectives of this program. Ii. Demonstration of benefits in addressing the needs of the transit agency and industry and impacts to infrastructure, equipment, transit workforce, and riders.

Iii. Degree of improvement over current and existing technologies, designs, and/or practices applicable to the transit industry. B. Project Approach i. Quality of the project approach such as existing partnerships, collaboration strategies and level of commitment of the project partners.

Ii. Proposal is realistic in its approach to fulfill the milestones/deliverables, schedule and goals. C. National Applicability i. Degree to which the project could be replicated by other transit agencies regionally or nationally.

Ii. Ability to evaluate technologies, designs and/or practices in a wide variety of conditions and locales. Iii. Degree to which the technology, designs and/or practices can be replicated by other transportation modes. D.

Commercialization and/or Knowledge Transfer i. Demonstrates a realistic plan for moving the results of the project into the transit marketplace (patents, conferences, articles in trade magazines, webinar, site visits, etc.). Ii. How the project team plans to work with the industry on improving best practices, guidance and/or standards, if applicable. Iii.

Demonstrate a clear understanding and robust approach to data collection, access and management. E. Technical, Legal and Financial Capacity Capacity of the applicant and any partners to successfully execute the project effort. There should be no outstanding legal, technical, or financial issues with the applicant that would make this a high-risk project. (2) Review and Selection Process An FTA technical evaluation committee will evaluate proposals based on the published project evaluation criteria.

Members of the technical evaluation committee will rate the applications and may seek clarification about any statement in an application. The FTA Administrator will determine the final selection and amount of funding for each project after consideration of the findings of the technical evaluation committee. Geographic diversity, diversity of the project type, the amount of local match to be provided, and the applicant's receipt and management of other Federal transit funds may be considered in FTA's award decisions. Prior fare payment innovation efforts may receive priority consideration. The FTA Administrator will consider the following key DOT objectives.

A. Utilizing alternative funding sources and innovative financing models to attract non-Federal sources of investment. B. Whether the project is located in or supports public transportation service in a qualified opportunity zone designated pursuant to 26.U.S.C. 1400Z-1.

And c. The extent to which the project addresses challenges specific to the provision of rural public transportation. (3) FAPIIS Review Prior to making a grant award, FTA is required to review and consider any information about the applicant that is in the Federal Awardee Performance and Integrity Information System (FAPIIS) accessible through SAM. An applicant may review and comment on information about itself that a Federal awarding agency previously entered. FTA will consider any comments by the applicant, in addition to the other information in FAPIIS, in making a judgment about the applicant's integrity, business ethics, and record of performance under Federal awards when completing the review of risk posed by applicants as described in 2 CFR 200.205 Federal Awarding Agency Review of Risk Posed by Applicants.

F. Federal Award Administration Information (1) Federal Award Notices FTA will announce the final project selections on the FTA website. Project recipients should contact their FTA Regional Office for additional information regarding allocations for Start Printed Page 63657projects. At the time project selections are announced, FTA will extend pre-award authority for the selected projects. There is no blanket pre-award authority for these projects before announcement.

There is no minimum or maximum grant award amount, but FTA intends to fund as many meritorious projects as possible. FTA only will consider proposals from eligible recipients for eligible activities. Due to funding limitations, projects selected for funding may receive less than the amount originally requested. In those cases, applicants must be able to demonstrate that the proposed projects are still viable and can be completed with the amount awarded. (2) Administrative and National Policy Requirements a.

Pre-Award Authority FTA will issue specific guidance to recipients regarding pre-award authority at the time of selection. FTA does not provide pre-award authority for competitive funds until projects are selected, and there are Federal requirements that must be met before costs are incurred. For more information about FTA's policy on pre-award authority, see the FY 2020 Apportionments Notice published on June 3, 2020, at https://www.govinfo.gov/​content/​pkg/​FR-2020-06-03/​pdf/​2020-11946.pdf. b. Grant Requirements Selected applicants will submit a grant application through FTA's electronic grant management system and adhere to the customary FTA grant requirements for research project (insert Circular name).

All competitive grants, regardless of award amount, will be subject to the Congressional notification and release process. FTA emphasizes that third-party procurement applies to all funding awards, as described in FTA Circular 4220.1F, “Third Party Contracting Guidance.” However, FTA may approve applications that include a specifically identified partnering organization(s) (2 CFR 200.302(f)). When included, the application, budget, and budget narrative should provide a clear understanding of how the selection of these organizations is critical for the project and give sufficient detail about the costs involved. C. Planning FTA encourages applicants to engage the appropriate State Departments of Transportation, Regional Transportation Planning Organizations, or Metropolitan Planning Organizations in areas to be served by the project funds available under this program.

D. Standard Assurances The applicant assures that it will comply with all applicable Federal statutes, regulations, executive orders, FTA circulars, and other Federal administrative requirements in carrying out any project supported by the FTA grant. The applicant acknowledges that it is under a continuing obligation to comply with the terms and conditions of the grant agreement issued for its project with FTA. The applicant understands that Federal laws, regulations, policies, and administrative practices might be modified from time to time and may affect the implementation of the project. The applicant agrees that the most recent Federal requirements will apply to the project unless FTA issues a written determination otherwise.

The applicant must submit the Certifications and Assurances before receiving a grant if it does not have current certifications on file. E. Free Speech and Religious Liberty In connection with any program or activity conducted with or benefiting from funds awarded under this notice, recipients of funds must comply with all applicable requirements of Federal law, including, without limitation, the Constitution of the United States. Statutory, regulatory, and public policy requirements, including without limitation, those protecting free speech, religious liberty, public welfare, the environment, and prohibiting discrimination. The conditions of performance, non-discrimination requirements, and other assurances made applicable to the award of funds in accordance with regulations of the Department of Transportation.

And applicable Federal financial assistance and contracting principles promulgated by the Office of Management and Budget. In complying with these requirements, recipients must ensure that no concession agreements are denied or other contracting decisions made on the basis of speech or other activities protected by the First Amendment. If the Department determines that a recipient has failed to comply with applicable Federal requirements, the Department may terminate the award of funds and disallow previously incurred costs, requiring the recipient to reimburse any expended award funds. (3) Reporting The post-award reporting requirements include submission of the Federal Financial Report (FFR) and Milestone Progress Report in TrAMS. An evaluation of the grant will occur at various points in the demonstration process and at the end of the project.

In addition, FTA is responsible for producing an Annual Report to Congress that compiles evaluation of selected projects, including an evaluation of the performance measures identified by the applicants. All applicants must develop an evaluation plan to measure the success or failure of their projects and describe any plans for broad-based implementation of successful projects. FTA may request data and reports to support the evaluation and Annual Report. A. Independent Evaluation To achieve a comprehensive understanding of the impacts and implications of each proposed buy antibiotics Research Demonstration Program, projects funded under this announcement will require the recipient to conduct a third party independent evaluation of their project.

Recipients will be required to contract with a third party independent evaluator to assist in developing an evaluation plan, and collecting, storing and managing data required to fulfill the evaluation requirement. No more than 10 percent of the Federal share of the project may be used to hire the third-party independent evaluator and the inclusion of a third-party independent evaluation should be described in the grant application. If the project duration is more than two years, an interim evaluation report would need to be submitted to FTA, otherwise the evaluation report should be included as part of the final project report. B. buy antibiotics Research Demonstration Grant Program Evaluation Projects funded under this announcement will be required to establish a set of performance metrics set by the third-party independent evaluator and shared with FTA.

G. Federal Awarding Agency Contacts Information For questions about applying, please contact Jamel El-Hamri email. Jamel.El-Hamri@dot.gov phone. 202-366-8985. A TDD is available at 1-800-877-8339 (TDDFIRS).

To ensure that applicants receive accurate information about eligibility or the program, applicants are encouraged to contact FTA directly with questions, rather than through intermediaries or third parties.Start Printed Page 63658 FTA staff also may conduct briefings on the competitive grants selection and award process upon request. Start Signature K. Jane Williams, Deputy Administrator. End Signature End Supplemental Information [FR Doc. 2020-22316 Filed 10-7-20.

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Etchells E, Ho M, Shojania cheap amoxil online KG click this over here now. Value of small sample sizes in rapid-cycle quality improvement projects. BMJ Qual Safe 2016;25:202–6.The article has cheap amoxil online been corrected since it was published online.

The authors want to alert readers to the following error identified in the published version. The error is in the last paragraph of the section “Small samples can make ‘rapid improvement’ Rapid”, wherein the minimum sample size has been considered as six instead cheap amoxil online of eight.For this first (convenience) sample of 10 volunteer users, 5/10 (50%) completed the form without any input or instructions. The other five became frustrated and gave up.

Table 1 tells you that, with an observed success rate of 50% and a desired target of 90%, any audit with a sample of six or more allows you to confidently reject the null hypothesis that your form is working at a cheap amoxil online 90% success rate.For decades, those working in hospitals normalised the incessant alarms from medical devices as a necessary, almost comforting, reality of a high tech industry. While nurses drowned in excessive, frequently uninformative alarms, other members of the healthcare team often paid little attention. Fortunately, times are changing and managing alarm fatigue is now a key patient safety priority in acute care environments.1Adverse patient events from alarm fatigue, particularly related to excessive physiological monitor alarms, have received widespread attention over the last decade, including from the news media.2–5 In the USA, hospitals redoubled alarm safety efforts following the 2013 Joint Commission Sentinel Event Alert and subsequent National Patient Safety Goals on alarm safety.1 2 6 We are now beginning to understand how to reduce excessive non-actionable alarms (including invalid alarms as cheap amoxil online well as those that are valid but not actionable or informative),7 8 better manage alarm notifications and ultimately improve patient safety.

Alarm data are readily available and measuring alarm response time during patient care is possible.7 9 Yet we have few high-quality reports describing clear improvement to clinical alarm burden, and most published interventions are of limited scope, duration or both.10 11 To demonstrate value in alarm quality improvement (QI) efforts moving forward, we need more rigorous evidence for interventions and more meaningful outcome measures.In this issue of BMJ Quality and Safety, Pater et al12 report the results of a comprehensive multidisciplinary alarm management QI project executed over 3½ years in a 17-bed paediatric acute care cardiology unit. The primary project goal was to reduce cheap amoxil online alarm notifications from continuous bedside monitoring. Although limited to a single unit, the project is an important contribution to the scant literature on alarm management in paediatric settings for three reasons.

First, the initiative lasted longer than most that have been reported, which allowed for tailoring of alarm interventions to the needs of the unit and patient population and measuring the impacts and sustainability over time. Second, the scope of the intervention bundle encompassed a wide variety of changes including cheap amoxil online adoption of a smartphone notification system. Addition of time delays between when alarm thresholds are violated and when an alarm notification is issued.

Implementation of an cheap amoxil online alarm notification escalation algorithm after a certain amount of time in alarm threshold violation. Deactivation of numerous technical alarms (such as respiratory lead detachment). Monitoring of electrode cheap amoxil online lead replacement every 24 hours.

And discussion of alarm parameters on daily rounds. Third, the authors cheap amoxil online introduced a novel strategy for reducing the stress that alarms may cause patients and families by deactivating inroom alarm audio, although no outcomes were reported attributable directly to this component of the intervention.This project constitutes an important contribution to the published literature. However, Pater et al faced two challenges that are ubiquitous in the field of clinical alarm management.

(1) Identification of meaningful outcome measures and (2) Lack cheap amoxil online of high-quality evidence for most interventions. With regards to the first challenge, the primary outcome measure used in the study comprised ‘initial alarm notifications’, defined as the first notification of a monitor alarm delivered to the nurse’s mobile device. Although initial alarm notifications declined by 68% following the intervention, these notifications accounted for only about half of all alarm notifications.

The other half included second and third notifications for alarms exceeding specified delay thresholds, which were sent both to the mobile device of the primary nurse and to ‘buddy’ nurses, potentially cheap amoxil online increasing alarm burden. On the other hand, eliminating inroom audible alarms may have reduced the perceived alarm burden for nurses compared with having both bedside and mobile device notifications. Determining the true benefit of a reduction in a subset of alarms presents complex challenges.Alarm frequency is the most commonly used outcome measure in alarm research and QI projects, but cheap amoxil online reduction in alarms does not necessarily indicate improved patient safety or a highly functional alarm management system.

Alarm reduction could easily be achieved in an undesirable way by simply turning off alarms. Unfortunately, most studies have cheap amoxil online not been powered to statistically evaluate improvements in patient safety. (Pater et al did monitor patient safety balancing measures, which remained stable after intervention implementation).

To assess change in nurses’ perceptions of alarm frequency, Pater et al cheap amoxil online conducted a prepost survey, which despite the small sample size (n=38 preintervention and n=25 postintervention) managed to show improvement, with the percentage of nurses agreeing they could respond to alarms appropriately and quickly increasing from 32% to 76% (p<0.001). That said, this survey was not a validated measure of alarm fatigue. In fact, we currently have no widely accepted, validated tool for assessing alarm fatigue.11As we look towards future evaluations of alarm management strategies, the focus cheap amoxil online needs to shift away from simply reducing the frequency of alarms to more meaningful outcome metrics.

In addition to alarm rates, outcomes such as response time to actual patient alarms7 9 or to simulated alarms injected into real patient care environments13 may be better indicators of whether the entire alarm response system is functioning correctly. Larger, multisite studies are needed to assess patient outcomes.In addition to meaningful outcome measures, the second challenge for alarm QI projects is the lack of good evidence for alarm management interventions. Most alarm reduction interventions have not cheap amoxil online been systematically evaluated at all or only in small studies without a control group.10 11 As a result, alarm management projects tend to involve complex and costly bundles of interventions of uncertain benefit.

The cost of these interventions is due in part to the growing industry of technology solutions for alarm management. Some institutions have also made massive investments in personnel, such as monitor ‘watchers’ to help nurses identify cheap amoxil online actionable alarms, for which there is also little evidence.14Future alarm management QI initiatives will benefit from a higher quality evidence base for the growing list of potential alarm management interventions. Pragmatic trials that leverage meaningful outcome measures to assess alarm interventions are warranted.

In addition, we need to evaluate interventions that address the full spectrum of the alarm management system cheap amoxil online. Most alarm management interventions to date have focused primarily on filtering out non-actionable alarms. Far less emphasis has been placed on ensuring that the nurse receiving the notification is cheap amoxil online available to respond to the alarm, a prime opportunity for future work.Even if alarms are actionable, we know that nurses may not always respond quickly for a variety of reasons.7 15–17 Factors like insufficient staffing, high severity of illness on the unit and unbalanced nursing skill mix all likely contribute to inadequate alarm response.

In critical care, nurses have reported that the nature of their work requires that they function as a team to respond to one another’s alarms.15 Although not ideal, nurses have developed heuristics based on factors like family presence at the bedside to help them prioritise alarm response in hectic work environments.7 16 Emphasising outcomes like faster alarm response time without addressing systems factors risks trading one patient safety problem for another. We do not want to engender more frequent interruptions of high-risk activities, like cheap amoxil online medication administration,18 19 because nurses feel compelled to respond more quickly to alarms.The robust QI initiative carried out by Pater et al reflects the type of thoughtful approach needed to implement and tailor alarm management interventions for a particular unit, demonstrating a generalisable process for others to emulate. Ultimately, every alarm offers a potential benefit (opportunity to rescue a patient) and comes with a potential cost (eg, increased alarm fatigue, interruptions of other activities).

This trade-off needs to be optimised in the context of the individual unit, accounting for the unit-specific and systems factors that influence the cost of each additional alarm, including non-actionable alarm rates, unit layout, severity of illness and nurse staffing.17 20 With more robust outcome measures and more evidence to support interventions, we can increase the value of alarm QI initiatives and accelerate progress towards optimising alarm management systems.AcknowledgmentsWe thank Charles McCulloch, PhD (University of California, San Francisco) for comments on an early draft..

Etchells E, Ho M, Shojania KG where can you buy amoxil over the counter. Value of small sample sizes in rapid-cycle quality improvement projects. BMJ Qual Safe 2016;25:202–6.The article has been where can you buy amoxil over the counter corrected since it was published online. The authors want to alert readers to the following error identified in the published version.

The error is in the last paragraph of the section “Small samples can make ‘rapid improvement’ Rapid”, wherein the minimum sample size has been considered as six instead of eight.For this first (convenience) sample of 10 volunteer users, 5/10 (50%) completed the form without where can you buy amoxil over the counter any input or instructions. The other five became frustrated and gave up. Table 1 tells you that, with an observed success rate of 50% and a desired target of 90%, any audit with a sample of six or more allows you to confidently reject the null hypothesis that where can you buy amoxil over the counter your form is working at a 90% success rate.For decades, those working in hospitals normalised the incessant alarms from medical devices as a necessary, almost comforting, reality of a high tech industry. While nurses drowned in excessive, frequently uninformative alarms, other members of the healthcare team often paid little attention.

Fortunately, times are changing and managing alarm where can you buy amoxil over the counter fatigue is now a key patient safety priority in acute care environments.1Adverse patient events from alarm fatigue, particularly related to excessive physiological monitor alarms, have received widespread attention over the last decade, including from the news media.2–5 In the USA, hospitals redoubled alarm safety efforts following the 2013 Joint Commission Sentinel Event Alert and subsequent National Patient Safety Goals on alarm safety.1 2 6 We are now beginning to understand how to reduce excessive non-actionable alarms (including invalid alarms as well as those that are valid but not actionable or informative),7 8 better manage alarm notifications and ultimately improve patient safety. Alarm data are readily available and measuring alarm response time during patient care is possible.7 9 Yet we have few high-quality reports describing clear improvement to clinical alarm burden, and most published interventions are of limited scope, duration or both.10 11 To demonstrate value in alarm quality improvement (QI) efforts moving forward, we need more rigorous evidence for interventions and more meaningful outcome measures.In this issue of BMJ Quality and Safety, Pater et al12 report the results of a comprehensive multidisciplinary alarm management QI project executed over 3½ years in a 17-bed paediatric acute care cardiology unit. The primary project goal where can you buy amoxil over the counter was to reduce alarm notifications from continuous bedside monitoring. Although limited to a single unit, the project is an important contribution to the scant literature on alarm management in paediatric settings for three reasons.

First, the initiative lasted longer than most that have been reported, which allowed for tailoring of alarm interventions to the needs of the unit and patient population and measuring the impacts and sustainability over time. Second, the scope of the intervention bundle encompassed a wide variety of changes including adoption of a smartphone notification where can you buy amoxil over the counter system. Addition of time delays between when alarm thresholds are violated and when an alarm notification is issued. Implementation of an where can you buy amoxil over the counter alarm notification escalation algorithm after a certain amount of time in alarm threshold violation.

Deactivation of numerous technical alarms (such as respiratory lead detachment). Monitoring of electrode lead replacement every 24 hours where can you buy amoxil over the counter. And discussion of alarm parameters on daily rounds. Third, the authors introduced where can you buy amoxil over the counter a novel strategy for reducing the stress that alarms may cause patients and families by deactivating inroom alarm audio, although no outcomes were reported attributable directly to this component of the intervention.This project constitutes an important contribution to the published literature.

However, Pater et al faced two challenges that are ubiquitous in the field of clinical alarm management. (1) Identification of meaningful outcome measures and (2) Lack where can you buy amoxil over the counter of high-quality evidence for most interventions. With regards to the first challenge, the primary outcome measure used in the study comprised ‘initial alarm notifications’, defined as the first notification of a monitor alarm delivered to the nurse’s mobile device. Although initial alarm notifications declined by 68% following the intervention, these notifications accounted for only about half of all alarm notifications.

The other half included second and third notifications where can you buy amoxil over the counter for alarms exceeding specified delay thresholds, which were sent both to the mobile device of the primary nurse and to ‘buddy’ nurses, potentially increasing alarm burden. On the other hand, eliminating inroom audible alarms may have reduced the perceived alarm burden for nurses compared with having both bedside and mobile device notifications. Determining the where can you buy amoxil over the counter true benefit of a reduction in a subset of alarms presents complex challenges.Alarm frequency is the most commonly used outcome measure in alarm research and QI projects, but reduction in alarms does not necessarily indicate improved patient safety or a highly functional alarm management system. Alarm reduction could easily be achieved in an undesirable way by simply turning off alarms.

Unfortunately, most studies have not been powered to statistically evaluate improvements in where can you buy amoxil over the counter patient safety. (Pater et al did monitor patient safety balancing measures, which remained stable after intervention implementation). To assess change in where can you buy amoxil over the counter nurses’ perceptions of alarm frequency, Pater et al conducted a prepost survey, which despite the small sample size (n=38 preintervention and n=25 postintervention) managed to show improvement, with the percentage of nurses agreeing they could respond to alarms appropriately and quickly increasing from 32% to 76% (p<0.001). That said, this survey was not a validated measure of alarm fatigue.

In fact, we currently have no widely accepted, validated tool for assessing alarm fatigue.11As we look towards future evaluations of alarm management strategies, the focus needs to shift where can you buy amoxil over the counter away from simply reducing the frequency of alarms to more meaningful outcome metrics. In addition to alarm rates, outcomes such as response time to actual patient alarms7 9 or to simulated alarms injected into real patient care environments13 may be better indicators of whether the entire alarm response system is functioning correctly. Larger, multisite studies are needed to assess patient outcomes.In addition to meaningful outcome measures, the second challenge for alarm QI projects is the lack of good evidence for alarm management interventions. Most alarm reduction interventions have not been where can you buy amoxil over the counter systematically evaluated at all or only in small studies without a control group.10 11 As a result, alarm management projects tend to involve complex and costly bundles of interventions of uncertain benefit.

The cost of these interventions is due in part to the growing industry of technology solutions for alarm management. Some institutions have also made massive investments in personnel, such as monitor ‘watchers’ to where can you buy amoxil over the counter help nurses identify actionable alarms, for which there is also little evidence.14Future alarm management QI initiatives will benefit from a higher quality evidence base for the growing list of potential alarm management interventions. Pragmatic trials that leverage meaningful outcome measures to assess alarm interventions are warranted. In addition, we need to evaluate interventions where can you buy amoxil over the counter that address the full spectrum of the alarm management system.

Most alarm management interventions to date have focused primarily on filtering out non-actionable alarms. Far less emphasis has been placed on ensuring where can you buy amoxil over the counter that the nurse receiving the notification is available to respond to the alarm, a prime opportunity for future work.Even if alarms are actionable, we know that nurses may not always respond quickly for a variety of reasons.7 15–17 Factors like insufficient staffing, high severity of illness on the unit and unbalanced nursing skill mix all likely contribute to inadequate alarm response. In critical care, nurses have reported that the nature of their work requires that they function as a team to respond to one another’s alarms.15 Although not ideal, nurses have developed heuristics based on factors like family presence at the bedside to help them prioritise alarm response in hectic work environments.7 16 Emphasising outcomes like faster alarm response time without addressing systems factors risks trading one patient safety problem for another. We do not want to engender more frequent interruptions of high-risk activities, like medication administration,18 19 because nurses feel compelled to respond more quickly to alarms.The robust where can you buy amoxil over the counter QI initiative carried out by Pater et al reflects the type of thoughtful approach needed to implement and tailor alarm management interventions for a particular unit, demonstrating a generalisable process for others to emulate.

Ultimately, every alarm offers a potential benefit (opportunity to rescue a patient) and comes with a potential cost (eg, increased alarm fatigue, interruptions of other activities). This trade-off needs to be optimised in the context of the individual unit, accounting for the unit-specific and systems factors that influence the cost of each additional alarm, including non-actionable alarm rates, unit layout, severity of illness and nurse staffing.17 20 With more robust outcome measures and more evidence to support interventions, we can increase the value of alarm QI initiatives and accelerate progress towards optimising alarm management systems.AcknowledgmentsWe thank Charles McCulloch, PhD (University of California, San Francisco) for comments on an early draft..