Dosimeter Location and Measured Effective Radiation Dose in Pain Management Physicians
Phase: NA
Conditions: RAD
Sponsor: Oregon Health and Science University

 
 
 
 
 
 
 
 
Dosimeter Location and Measured Effective Radiation Dose in Pain Management Physicians 
 
 
NCT06309407 
 
May 7, 2024 
 

 
1. Protocol Title: 
 
Dosimeter Location and Measured Effective Radiation Dose in Pain Management 
Physicians  
 
2. Objectives 
 
The primary objective is to determine if there is a significant difference in radiation readings 
between dosimeters worn on the chest versus the hand of interventional pain management 
physicians and elucidate which dosimeter had higher readings.  
 
The secondary objectives are to examine trends in radiation exposure in each group (chest 
only or chest plus hand) over the course of the study to understand if overall radiation 
exposure decreases over time due to changes in practice habits as a response to exposure 
reports. The last objective will be to track incidences of physician glove breaches in both 
groups to assess if wearing hand dosimeters is associated with an increased risk of the event.  
 
3. Background 
 
Radiation producing imaging use is ubiquitous in medicine with a wide range of imaging 
modalities. Of these, computed tomography (CT) and fluoroscopy are the most commonly 
used and are associated with some of the highest radiation exposure for patients and 
operators.1-2 This is particularly important in fields such as Interventional Pain Management 
where these modalities are essential to daily practice. The utilization of opioid-sparing 
minimally invasive techniques for low back pain and arthritis using CT and fluoroscopy has 
expanded over the years which has greatly increased radiation exposure among pain 
specialists.  
 
Current Occupational Safety & Health Administration (OSHA) guidelines for occupational 
dose limitations indicate that the total maximum effective dose to the head and trunk is 12.5 
mSv per calendar quarter and 187.5 mSv per quarter for the hands and feet.4 Complications 
of acute and chronic radiation exposure can include tissue reactions such as skin burns and 
cataracts or stochastic affects like cancer or hereditary derangements.5  
 
Spatial relationship to the imaging device, imaging type, and technical execution of the 
procedure all affect the amount of radiation physicians and patients are exposed to. In terms 
of equipment location, the highest levels of radiation in C-arm fluoroscopy is very close to 
the physician’s waist and abdomen.6 Discrepancy in exposure among imaging type is noted 
by Hoang et al who showed that CT guided techniques have approximately half the 
effective dose to physicians compared to conventional fluoroscopy techniques.12 However 
this is not without a tradeoff, as procedures such as epidural steroid injections under CT 
guidance are associated with more than eight times the radiation dose to patients as 
compared to fluoroscopy guided.13 Thankfully, techniques that incorporate the benefits of 
both such as ultralow-dose CT are being popularized, which actually has a lower does than 
traditional fluoroscopy to the patient.22 

 
As one might imagine, this highly variable and multifaceted nature of radiation exposure 
can potentially lead to large effective doses at one time. Several studies from other 
specialties found that the radiation exposure to vulnerable body parts like the eyes, thyroid, 
and hands often meet acceptable levels but could be easily and significantly affected based 
on physician practices; particularly by the improper use of personal protective equipment, 
patient positioning, and work ergonomics.16-19 Perhaps unsurprisingly, a review by Martin 
shows that, in radiologists and cardiologists, the hands are the part of the body most affected 
by work practice and positioning when it comes to radiation exposure and the author highly 
recommends the use of a hand dosimeter.20 Stoeckelhuber et al. noted that interventionalists 
performing procedures under CT that expose their hand to the primary beam can receive an 
effective radiation dose of up to 0.6 mSv in procedures lasting only 20 seconds.8 At this 
rate, if a physician were to use fluoroscopy in this manner for a two-minute procedure, they 
would only be able to safely preform a mere 52 procedures per calendar quarter to maintain 
OSHA safety standards.  
 
The use of multiple protective measures such as long needle holders, protective gloves, and 
lead drapes is considered the gold standard in practice and have been shown to decrease 
dose rates by up to 99.6% overall.8,14 Similarly, Hoffler et al found that, when compared to 
no protective measures, just the use of attenuating gloves and leaded eye protection can 
reduce the radiation exposure to the hands and eyes by 69.4% and 65.6% respectively.21 
However, in a survey of 708 interventional pain physicians, 93% stated they were concerned 
with radiation exposure but only 63% had formal safety training and there was low overall 
understanding of evidence-based radiation safety practices.9 Therefore, better understanding 
of a physician’s individual practices on effective radiation dose through a quality 
improvement study will help to close gaps in knowledge and understanding of exposure.  
 
A dosimeter is a small device which measures the radiation the physician receives from 
their practice. There are several different kinds of dosimeters including the commonly worn 
chest monitor and others closer to the hands of the physician, such as wrist bands or rings. 
Carinou et al indicate that these devices are overall generally accurate at measuring the 
correct radiation dose but have their limitations depending on the manufacturer, scope of 
intended use, and material composition.15 There are currently no studies comparing 
dosimeter location and radiation exposure readings in pain management physicians. The 
effective dose detected by a single chest monitor is likely not an accurate representation of 
the does received in other parts of the body in pain management physicians. There are also 
no published studies assessing the risk of wearing hand dosimeters in sterile procedures, 
such as increased frequency of glove breaches or procedure-related infections. 
 
Of the various factors that influence radiation exposure risk, dosimeter location on a 
proceduralists body is of particular interest to interventional pain physicians. Yamashita et 
al. found a large discrepancy in dosimeter readings among spine surgeons using fluoroscopy 
between the dosimeters worn on the chest (125.6 mSv) and those worn on the thumb (368 
mSv).10 This discrepancy indicates that the hands of proceduralist may be exposed to 
radiation exceeding the acceptable safe limit despite a chest worn dosimeter measuring safe 
radiation levels. This has obvious and dangerous implications for individuals that only wear 

a chest dosimeter.  
 
Our review of literature identifies a knowledge gap between dosimeter location and 
radiation risk among interventional pain physicians. This evidence supports the need of a 
quality improvement study to further assess radiation exposure in pain management 
physicians. In order to ensure physician safety, it is crucial to have adequate radiation 
exposure training and protective equipment as well as accurate measurements of effective 
radiation dose. This is particularly important with parts of the body such as the hands where 
effective radiation dose may be much higher than being recorded on chest dosimeters. This 
quality improvement study will be essential to providing valuable insight into radiation 
exposure and may help guide safety protocols in the future for OHSU physicians.  
 
In sum, the variability in effective radiation dose based on procedure type, imaging 
modality, protective equipment and procedural approach requires further investigation into 
dosimeter location to accurately evaluate provider safety during radiation generating 
procedures. 
 
4. Study Design 
 
This is a prospective quality and safety improvement study designed to examine potential 
differences in radiation measurements depending on dosimeter location on an interventional 
pain medicine practitioner’s body. The comparison will be made between a group wearing 
chest worn dosimeters (control) and chest plus hand worn dosimeters (experimental) between 
October 1, 2022 and April 21, 2023.   
 
The study will be performed at the Comprehensive Pain Center at Oregon Health and Science 
University (OHSU) and involve attending physicians and fellow physicians who consent to 
participate. The physicians who consent will then be randomly assigned by a computer-
generated program to either the control group (chest dosimeter) or experimental group (chest 
plus hand dosimeter). 
 
The control group will be assigned a chest dosimeter to wear while the experimental group 
will be assigned a hand and chest dosimeter. The dosimeters will be collected according to 
standard processing protocol every three month(s) by the designated Comprehensive Pain 
Center dosimeter collector. The badges will then be submitted to the vendor, Mirion, who 
will process the dosimeters and return an electronic report available for viewing online and at 
the procedure area nursing station. All study participants will also be emailed a copy of the 
report.  
 
The study team will assess physician compliance with wearing the dosimeter(s) by having 
the procedure nurses perform a daily written audit of chest and hand dosimeter presence or 
absence.  
 
Radiation measurements and compliance logs will be recorded inOHSU Microsoft Teams 

Excel. We are done collecting data. We are using Microsoft Excel in Teams to input and 
analyze the data. Data analysis will be performed by an OHSU statistician. 
 
Consistent with the OHSU standards for wearing hand dosimeters for sterile procedures, for 
each procedure the physician wearing the hand dosimeter will be required to:  
 
1) Wash the hand dosimeter with one pump (2 mL) of Avaguard 
2) Place the hand dosimeter on a bare hand 
3) Dispense one pump (2 ml) into the palm of one hand. Dip fingertips of the opposite 
hand into the hand prep and work under fingernails. Spread remaining hand prep 
over the hand and up to just above the elbow.  
4) Dispense one pump (2 ml) and repeat procedure with opposite hand. 
5) Dispense final pump (2 ml) of hand prep into either hand and reapply to all aspects 
of both hands up to the wrists. Allow to dry. Do not use towels to dry. 
6) Double glove both hands using sterile gloves.  
 
At the conclusion of each procedure, the physicians in both groups will be required to inspect 
their surgical gloves for any visible breaches. All breaches of one or both gloves on each 
hand that are recognized during or after the procedure must be reported to the study team. 
The physician will also indicate on which hand the hand dosimeter, if applicable, was worn.  
 
 
5. Study Population 
 
Inclusion and Exclusion Criteria 
Inclusion criteria includes: 
a. Physicians actively performing fluoroscopy procedures at the OHSU 
Comprehensive Pain Center.  
Exclusion criteria includes: 
a. Those that do not want to participate in the quality improvement project. 
 
Number of Subjects 
Of 6 attending physicians and 4 fellows that qualify for the study, we anticipate 8 
participants in the study.  
 
Vulnerable Populations 
a. Vulnerable populations are not involved in this quality improvement study. 
 
6. Setting 
The study examines radiation exposure of OHSU physicians performing their routine 
medical practice at the OHSU Comprehensive Pain Center Procedure Rooms 1 and 2. Hand 
dosimeters are currently used at OHSU in other departments. All study activities will take 
place at OHSU or remotely using OHSU provided secure computers, by OHSU personnel. 
 
7. Recruitment Methods 

Volunteers will be recruited through OHSU email. Consent to participate will be collected 
prior to the start of the study.    
 
8. Consent Process 
Participants will be de-identified in OHSU Microsoft Teams Excel. Individual consents will 
be obtained from Comprehensive Pain Center physicians prior to the start of the data 
collection period. For all procedure patients, standard procedure informed consent will be 
obtained. 
 
9. Procedures 
The study team will directly input data collected from dosimeters and compliance reports 
into OHSU Microsoft Teams Excel.  
 
The variables that will be recorded in OHSU Microsoft Teams Excel for each participant 
will include: 
a. Group identifier – control or experimental 
b. Chest dosimeter radiation exposure reading (Total Effective Dose Equivalent in 
rem) for each 3-month period  
c. Hand dosimeter radiation exposure reading (Total Effective Dose Equivalent in 
rem) for each 3-month period  
d. Dosimeter compliance for each 3-month period (%) 
e. Report(s) and date(s) of glove breaches during the procedure 
 
10. Data and Specimens 
Handling of Data and Specimens 
No specimens will be collected for this study. OHSU Microsoft Teams Excel will be 
used for data collection and storage. No identifiers will be collected that could link the 
participant to published data. Access to data is restricted to study personnel and access 
to data requires OHSU ID/password authentication.  
 
11. Sharing of Results with Subjects 
The study results will be published. 
 
12. Data and Specimen Banking 
Data will not be stored for future research. Data will be retained for up to 3 years or until the 
study is completed and results are published. 
 
13. Data Analysis 
For the statistical analysis, to perform hypothesis testing, the statistician will use a t-test 
between dosimeter type and effective radiation dose. 
 
The statistician will perform an analysis using descriptive statistics, tables, and data 
visualization techniques. The statistics will include median (min, max) and mean (SD) with 
95% confidence intervals for continuous variables and frequencies and proportions for binary 
and categorical variables. The statistician will use multiple imputation to address missing 
data if the missing rate is more than 10%.  Multiple imputation by chained equations (MICE) 

is implemented assuming missing at random. 
 
14. Privacy, Confidentiality and Data Security 
Access to data during the study period is restricted to study personnel and access to data 
requires OHSU ID/password authentication. 
 
Data for this project will be stored in Microsoft Teams Excel 
 
The study team will not collect protected health information.  
 
Standard institutional practices will be followed as described by the OHSU Information 
Security Directives at the following link: 
http://www.ohsu.edu/xd/about/services/integrity/policies/ipspolicies-info-sec-
directiv.cfm#results to maintain the confidentiality and security of data collected in this 
study.  
 
Study staff will be trained with regard to these policies. Electronic data will be stored on 
encrypted: computers, laptops, tablets, and iPads. 
 
Electronic data is stored:  
• On restricted drives on the OHSU network.  
 
• OHSU Microsoft Teams Excel 
 
Access to data is restricted to study personnel. Access to data requires OHSU ID/password 
authentication. 
 
15. Risks and Benefits  
a. Risk   
There is a risk of breach of confidentiality. There is no increased risk of radiation 
exposure to participants as they will not be asked to modify their routine medical 
practice in any way. There is a risk of hand dosimeters being associated with a glove 
breach. To address this risk, all physicians wearing hand dosimeters will be required 
to double glove per OHSU standards. There is no evidence of dosimeters causing 
increased risk to patients and standard procedure consent will be obtained per routine 
medical practice as is consistent with OHSU departments using hand dosimeters.  
 
b. Potential Benefits to Participants 
Identifying a discrepancy in radiation exposure between chest dosimeters and hand 
dosimeters that could lead to changes in provider radiation safety.  
 
 
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