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RATIONALE We have previously shown that hospital strain is associated with ICU admission and that ICU admission, compared to ward admission, may benefit certain patients with acute respiratory failure (ARF). OBJECTIVE To understand how strain-process-outcomes relationships in patients with ARF may vary among hospitals and what hospital practice differences may account for such variation. METHODS We examined high-acuity patients with ARF who did not require mechanical ventilation or vasopressors in the emergency department (ED) and were admitted to 27 U.S. hospitals from 2013 to 2018. Stratifying by hospital, we compared hospital strain-ICU admission relationships and hospital length of stay (LOS) and mortality among patients initially admitted to the ICU versus the ward using hospital strain as a previously validated instrumental variable. We also surveyed hospital practices and, in exploratory analyses, evaluated their associations with the above processes and outcomes. RESULTS There was significant among-hospital variation in ICU admission rates, hospital strain-ICU admission relationships, and in the association of ICU admission with hospital LOS and hospital mortality. Overall, ED patients with ARF (n = 45,339) experienced a 0.82-day shorter median hospital LOS if admitted initially to the ICU compared to the ward, but among the 27 hospitals (n = 224-3324) this effect varied from 5.85 days shorter (95% confidence interval [CI] -8.84--2.86, p < 0.001) to 4.38 days longer (95% CI 1.86-6.90, p = 0.001). Corresponding ranges for in-hospital mortality with ICU compared to ward admission revealed odds ratios (ORs) from 0.08 (95% CI 0.01-0.56, p < 0.007) to 8.89 (95% CI 1.60-79.85, p = 0.016) among patients with ARF (pooled OR = 0.75). In exploratory analyses, only a small number of measured hospital practices-the presence of a sepsis ED disposition guideline and maximum ED patient capacity-were potentially associated with hospital strain-ICU admission relationships. CONCLUSIONS Hospitals vary considerably in ICU admission rates, the sensitivity of those rates to hospital capacity strain, and the benefits of ICU admission for patients with ARF not requiring life support therapies in the ED. Future work is needed to more fully identify hospital-level factors contributing to these relationships.