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The purpose of this study was to assess Richmond Agitation Sedation Scale (RASS) goal implementation in mechanically ventilated patients sedated in the emergency department (ED), compliance with RASS, and goal achievement. This study was a retrospective chart review at a large Level I trauma academic medical center. Patients who were intubated in the ED or en route to the ED between October 1, 2013, and October 1, 2014, were eligible for inclusion if they met the following criteria: aged 18 years or older, 24 hr or more on mechanically ventilated support receiving continuous sedation and/or analgesia during the first 48 hr of admission, and a hospital stay of 6 days or more. There were 205 patients identified; 104 failed inclusion, 101 were enrolled, and 62 were excluded. Thirty-nine patients (94.9%) had an RASS goal implemented in the ED, of which 37 patients (81.1%) had an RASS goal set by an ED physician. Assessment of the RASS was found to be inconsistent, as 56.8% of patients were evaluated by an ED nurse within 1 hr of sedative initiation. Of the 37 patients who had an RASS goal in the ED, 18.9% achieved their goal in the ED. A review of sedation prescribing revealed that 39% received a regimen of varied combinations of continuous infusions of propofol, dexmedetomidine, and midazolam throughout admission, 33% received a regimen of 2 of the aforementioned drugs, and 28% received only propofol. Median extubation time was 129 hr. Seven patients expired within 180 days of admission. The assessment of the RASS was a common practice, but there were inconsistencies in measurement. A limited number of patients achieved their RASS goal in the ED. These results support a provider and nursing knowledge deficit regarding RASS goal setting, proper documentation of RASS measurement, and the need for appropriate assessments.