There may be no room in the inn, but the innkeepers sure are happy.

H andel and McConnell, 1 in comparing hospital profitability during times of high ambulance diversion versus none, demonstrate the unsur-prising conclusion that a full hospital enjoys greater profit than one less full. Given the perpetual myth of the emergency department (ED) as money loser, it is heart-ening to read that ED admissions yielded a higher per-patient profit than elective admissions. For this finding alone, this article should be kept in the ''key findings'' file of any ED director. They compare their results to those expected from a hotel with all rooms booked. The hospital is, indeed, a special kind of hotel. 2 Should you wish to spend the night, room availability does not matter. You may be placed on a couch in the lobby, possibly paying the same rates as if you were in the presidential suite. However, there will be no cable TV or wet bar for you or, for that matter, a hot meal or private bathroom. There is not even an obligation on the part of the hotel that an exhaustive search for a room should occur before you are placed in the lobby. In this sense, the authors are entirely correct that there is currently no financial disincentive to a hospital operating at greater than 100% capacity or, for that matter, stacking up admissions in the ED. There is a popular view that hospital administration (i.e., ''them''), in a Machiavellian fit of greed and disregard for patient safety, has created a system intent on maximizing profits. Furthermore, ED admissions are often considered less financially desirable. 3,4 In this view, ''they'' are perfectly content to have an ED full of boarded admissions. Although such a result may well be financially beneficial to the hospital, to say it was ''designed'' as such is to give credit where none is due. What we see is the result of an unanticipated evolution of both our patients' needs and what we can do to help, without concomitant evolution of when we can provide it. It should surprise no one that a system that provides a full solution 5 days a week cannot match a problem that occurs 7 days a week. 5 Ambulance diversion is but one of several examples of attempts to fit the patient to the system, rather than vice versa. In this relatively inflexible system, the ED serves as the primary point of flexibility. In effect, the ED …