Adoption of appropriate use criteria has not had a major impact on the frequency of "rarely appropriate" tests, with the rarely appropriate tests rate remaining at ∼20% in most institutions. We sought whether access to hand-held ultrasound (HHU) could be an alternative means of reducing rarely appropriate requests. We compared 2 approaches to rarely appropriate requests; "standard transthoracic echocardiography" (SE) as requested (control) and HHU as a gatekeeper (HHU). Patients were followed up for 6 months and assessed for end points including time until scan, repeat echocardiography/cost of either strategy, new major pathology, and change in management. The most common rarely appropriate requests in both groups were assessment of infective endocarditis without positive blood cultures and precordial murmur evaluation in absence of any other signs or symptoms of cardiovascular disease. The groups had comparable age, gender, requesting physician, and inpatient versus outpatient distribution. HHU led to a 59% reduction in rarely appropriate requests requiring SE. HHU significantly reduced time to decision for inpatients (0 [interquartile range 0, 1] vs 2 days [interquartile range 1, 4], p <0.001) and total cost of echocardiography (109 ± 86 vs 181 ± 37 USD, p <0.001). New major pathology was identified in 29% and 23% of HHU and SE, respectively. There was no difference with respect to change in management. In conclusion, HHU can be an effective gatekeeper to SE for rarely appropriate echocardiograms, reducing time to echocardiography and cost while satisfying the referring physician and avoiding repeat requests for SE. HHU provides a safety net that identifies potential important findings in rarely appropriate requests.