Launched with support from CHIBE and the Penn Medicine Center for Health Care Innovation, the Penn Medicine Nudge Unit is the world’s first behavioral design team embedded within the operations of a health system. Penn Medicine’s Nudge Unit, which launched in 2016, uses insights from behavioral economics and psychology to design and test approaches to steer medical decision-making and daily health behaviors toward higher value and improved patient outcomes.
Dr. Delgado follows in the footsteps of two CHIBE affiliates: Rinad Beidas, PhD, who was director of the Nudge Unit last year and is on CHIBE’s leadership team, and inaugural Director Mitesh Patel, MD, MBA, MS. Last year, Dr. Delgado served as deputy director of the Nudge Unit, alongside Srinath Adusumalli, MD, MSHP, MBMI.
“I am super excited to have the opportunity to build on the relationships that I have made working in emergency medicine interacting with outpatient and inpatient clinicians from every specialty to help facilitate and accelerate high-impact projects across the health system,” Dr. Delgado said of his new appointment.
Read our Q&A with the new director below:
Can you describe what kinds of behaviors the Nudge Unit is trying to influence?
Nudges aim to target situations where patients, clinicians, or others on the care team who are critical to good outcomes don’t make the right choice or it’s just too hard or inefficient to make the decision that achieves optimal health or operational outcomes. For example, our team aims to identify situations at Penn Medicine where an evidence-based practice is known and clinicians want to do it, but there is something getting in the way, such as clinicians having difficulty remembering to implement the evidence-based practice within a busy clinical encounter. On the patient side, we have similarly focused on nudging patients to do things that may be hard to remember, such as taking prescribed medications or keeping their My Penn Medicine profiles up to date to ensure clinicians have accurate information for them.
Tell us about one interesting project you and your team have worked on since you joined the Nudge Unit.
Our team has been working on how to engage patients coming into to the emergency department (ED) who are struggling with opioid use disorder (OUD) to initiate medications that have been proven to be lifesaving, facilitate recovery, and reduce complications from drug use. This is a huge evidence-based practice gap in health care. Collaborating with my colleagues Dr. Maggie Lowenstein and Dr. Jeanmarie Perrone, who are Addiction Medicine physicians, Rachel McFadden, an ED nurse, Dr. Rinad Beidas, and others, we sought to develop strategies that would make the screening and offering of evidence-based treatment a default process. We initially thought about developing a best practice alert for clinicians based on some elements in the electronic health record such as the patient chief complaint or prior history. However, we discovered this wouldn’t be accurate enough. We then conducted several focus groups with nurses and physicians, which caused us to pivot in a completely unexpected direction. The nurses expressed a desire to take on a more active role and suggested universally engaging patients during the triage screening process.
In the summer of 2021, we implemented a universal screen during nursing triage in which patients are asked if they are struggling with heroin, fentanyl, or painkillers, and informing them that we have resources to help. If patients screen positive, this instantly triggers nursing and physician prompts to assess level of withdrawal and use of an orderset with clinical decision support to initiate evidence-based treatment.
Our preliminary data demonstrates a significant increase in the initiation of life-saving medications among hospitals that adopted the screening pathway, and that this increase is equitable by sex, race, and ethnicity.
What I took away from this was the importance of stakeholder engagement and contextual inquiry to both optimize our intervention and successfully implement it. This is one of the big reasons I’m thrilled to be working with the Nudge Unit on leveraging behavioral and implementation science to change behavior.
How does your experience as attending physician in the emergency department inform your work at the Nudge Unit?
I think it’s a major privilege to work clinically as an emergency physician. Not only do I enjoy the clinical practice, but it provides a lens to see the needs — and particularly the unmet clinical and social needs — of the community. By talking to dozens of patients each shift and interacting with outpatient and inpatient physicians from every specialty, I can gain qualitative insights into a diverse range of pressing problems. These first-hand experiences have informed my research related to the COVID-19 response, the drug overdose epidemic, and violence, firearm, and motor vehicle injury — all of which are the leading causes of death in young and middle-aged adults.
Working in the emergency department is also the ultimate environment for observing judgements and decision making under uncertainty and pressured conditions. It is essentially the ideal lab for studying heuristics in decision making by both clinicians and patients. Having these experiences and exposures positions me to be well suited for a role that involves working with diverse teams on diverse clinical problems in diverse care settings.